Military Orthopedic Surgeons Are Not Just Traumatologists

ABSTRACT

Introduction

Each French military orthopedic surgeon is both an orthopedic surgeon and a trauma surgeon. Their mission is to support the armed forces in France and on deployment. The aim of this study was to describe the type of orthopedic surgery performed for the armed forces in France. Our hypothesis was that scheduled surgery was more common than trauma surgery.

Methods

We conducted a retrospective descriptive analysis of the surgical activity for military patients in the orthopedic surgery departments of the four French military platform hospitals. All surgical procedures performed during 2020 were collected. We divided the procedures into the following categories: heavy and light trauma, posttraumatic reconstruction surgery, sports surgery, degenerative surgery, and specialized surgery. Our primary endpoint was the number of procedures performed per category.

Results

A total of 827 individuals underwent surgery, 91 of whom (11%) were medical returnees from deployment. The surgeries performed for the remaining 736 soldiers present in metropolitan France (89%) consisted of 181 (24.6%) trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) scheduled surgery procedures (of which 60.8% were sports surgery). Among the medical returnees, there were 71 traumatology procedures (78%, of which 87.3% were light traumatology) and 20 procedures corresponding to surgery usually carried out on a scheduled basis (22%, of which 95% were sports surgery).

Conclusion

Military orthopedic surgeons are not just traumatologists; their activity for the armed forces is varied and mainly consists of so-called programmed interventions.

INTRODUCTION

The mission of military orthopedic surgeons is to support the armed forces in France and on deployment. This support is divided chronologically into three phases: before, during, and after deployment. A wealth of literature supports that surgical activity during deployments is focused solely on light and heavy trauma.^1–6 Thus, military orthopedic surgeons are often labeled as “trauma” surgeons. This confusion is exacerbated in France because orthopedics and traumatology are grouped under the same heading (same diploma); in contrast, these specialties are separated in United Kingdom or United States. However, although the surgical activity directly linked to deployment is easy to conceive, one should not neglect the periods before and after deployment. Before deployment, one must be at the service of the soldier in order to guarantee his or her aptitude for the forthcoming deployment (sports traumatology and functional surgery). After the deployment, one must manage the aftereffects of the trauma and meet the soldier’s functional needs.

The aim of this study was to describe the orthopedic surgical procedures for the armed forces that were performed in France. Our hypothesis was that traumatology was not the predominant activity of the military orthopedic surgeons for the armed forces.

METHODS

We conducted a retrospective quantitative and qualitative descriptive analysis of the surgical activity of the orthopedic surgery departments of the four French military platform hospitals (centers A, B, C, and D) for the benefit of military patients. We included all military patients who received operations in these hospitals. Civilian patients, nonoperated military patients, and foreign patients were excluded. Centers B and D were level 1 trauma centers (L1TCs).

We collected all orthopedic surgery procedures performed during the year 2020 and divided them into the following categories:

1. Heavy traumatology linked to high kinetic energy mechanisms: polytrauma and severe trauma, such as a fracture of the femur or pelvis, a fracture of the limbs, or a fracture with neurovascular complications;

2. Light traumatology: hand wounds, soft tissue infection, wrist or ankle fracture, or clavicle fracture;

3. Restorative surgery for traumatic sequelae (RSTS): pseudoarthrosis, amputation, tendon transfers, or nerve surgery;

4. Sports surgery: ligament reconstruction, joint stabilization, or tendon or cartilage repair;

5. Degenerative surgery: arthrosis, joint prosthesis, or chronic tendinopathy;

6. “Specialized” surgery: hand and foot surgery.

These categories were then grouped into major surgical groups: traumatology included heavy and light trauma, while regulated surgery included sports surgery, specialized surgery, degenerative surgery, and RSTS.

We then analyzed the activity according to the limb segment concerned, again using the above classification. We analyzed the procedures for the benefit of patients repatriated from deployment in the same way but separately. We compared the activities of the different hospitals, focusing on comparing the L1TCs with the other hospitals. A comparative statistical analysis (chi-square test) was performed to evaluate the differences in their activities, with P-values defined as significant if less than .5.

Our primary endpoint was the number of surgeries performed for each category of operative activity. Our hypothesis was that more scheduled surgeries than trauma surgeries were performed.

RESULTS

A total of 827 military personnel underwent surgery in the four main French military hospitals in 2020. Among them, 91 (11%) were medical returnees from deployment.

Analysis of Activity in France for the Benefit of Military Patients Not on Deployment (Table I)

Eighty-nine percent of the orthopedic surgical procedures performed on military personnel in France were in personnel present in France. Of the 736 total procedures in this group, 181 (24.6%) were trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) were scheduled procedures (of which 60.8% were sports surgery).

Analysis of the Activity Carried Out in France for the Benefit of Patients Repatriated From Deployment (Table II)

Ninety-one soldiers (11%) who underwent orthopedic surgery were repatriated from a deployment. Seventy-one (78%) of these were trauma procedures (of which 87.3% were light trauma) and 20 (22%) were scheduled procedures (of which 95% were sports surgery).

Comparative Analysis of Activity in France for the Benefit of Military Patients According to Whether the Location of the Surgery Was a Level 1 Trauma Centre

Table III illustrates that L1TCs and non-L1TCs had significantly different activities in all areas, with the exception of light trauma (P = .43). In particular:

1. 57% of trauma procedures were performed in L1TCs. Of these 103 procedures, 91.3% were heavy trauma and 52.2% were light trauma. The difference in the percentages of heavy trauma procedures (a total of 24 procedures) performed in non-L1TCs and L1TCs was statistically significant (21 and 3 procedures, respectively; P = 9.23.10⁷), as most of these surgeries were performed in L1TCs.

2. 56% of scheduled surgeries were performed in non-L1TCs, but L1TCs performed 90.3% of RSTS (P = 1.09.10⁹. Non-L1TCs had higher activities for specialized, sport, and degenerative surgeries, conducting 61.9%, 57%, and 62.3% of these surgeries, respectively (P = .0002, P = .0004, and P = .02, respectively).

3. 63.7% of those who were repatriated received operations in an L1TC. This difference was statistically significant (P = .0004).

Analysis of Overall Activity for the Benefit of the Military by Anatomical Location of Surgery

All of the body parts treated by orthopedic surgery are listed in Table IV, with a quantitative enumeration allowing us to find the proportion of surgeries performed on each body part. We found that the four most commonly treated body parts were the shoulder (13.8%), the hand (15.8%), the knee (30.2%), and the ankle (16.4%). For the subcategory of repatriated individuals, the four body parts on which most surgeries were performed were the hand (34.1%), knee (11.0%), ankle (16.5%), and foot (8.8%).

DISCUSSION

This original study was the first to our knowledge to describe the activity of military orthopedic surgeons in France for the armed forces. We deliberately excluded surgical activity during deployment, which has been widely described in the literature.^1–6

The military orthopedic surgical activity for the armed forces in France was rich and very diversified. It was not limited to traumatology, and the majority of the activity was intended to support military personnel stationed in France. The analysis of the data from this study confirmed our main hypothesis, as it showed that scheduled surgery (67.1%) was more common than trauma surgery (21.9%) or surgery to support repatriated soldiers (11.0%).

All subspecialties were analyzed. We found a predominance of sports surgery for patients in France, while light traumatology was the most common category for those repatriated from deployment. Surgeries were performed on all body parts, with variable distribution. The knee, the hand, and the ankle were the three most common locations for all patients combined (patients in metropolitan France and patients repatriated for medical reasons).

Trauma surgeries were in the minority. This finding suggested a recruitment bias. Indeed, apart from the activity dedicated to repatriates, recruitment was conducted locally (close to the center), and the French military hospital network is currently insufficient to allow exhaustive recruitment of military traumatology in France (i.e., the network does not include all of the medical units in France).

A comparative analysis of the L1TCs (centers B and D) compared to the non-L1TCs (A and C) showed significantly different activities: the activity of the L1TCs was more oriented toward heavy traumatology and RSTS, whereas the activity of the non-L1TC was predominantly in the other fields of programmed surgery.

Regulated surgery was largely dominated by sports surgery, which has a key role in maintaining the operational readiness of military personnel. In contrast, degenerative surgery was limited. This is because the military population is young, and any intervention for degenerative problems poses a problem of secondary aptitude, which inevitably reduces the rate of consultation and management for degenerative pathology. For example, a joint replacement for a degenerative joint makes it unfit for deployment.

In France, military orthopedic surgeons have general traumatology activity (upper and lower limbs) to maintain their skills on deployment, but they also all have a specialized, or even hyperspecialized, regulated activity, which is necessary for the optimal care of military patients. Therefore, like their civilian orthopedic colleagues, French military orthopedic surgeons are increasingly hyperspecialized with a predominantly regulated activity, even if they retain a secondary general trauma activity.

It is important to compare our results with the activities observed during exceptional events in France or the activity carried out on deployment. The literature allows us to obtain fairly clear information on these two contexts.

On deployment, the volume of surgical activity carried out within Role 3 is much more important than that in Role 2, with more than half of the surgeries performed as scheduled surgery to the benefit of the local population. Within advanced Role 2 surgical structures as deployed in Mali, more than 70% of the activity was performed as emergencies. Surgical indications were varied, ranging from emergency surgery to limb reconstructive surgery.^1–9 A lot of nonorthopedic procedures, such as vascular repairs and decompressive craniotomies, were also performed. The large variety and technical nature of the performed operations require the training of highly qualified military orthopedic surgeons with both experience in war surgery and management of aftereffects and complications. Orthopedists are also required to carry out procedures dealing with neurosurgery and general and/or vascular surgery on missions.^1–9

The Paris attacks in 2015 are an example that revealed the adaptation of military orthopedic surgeons facilitated by their experience from their deployments. They were able to quickly apply the rules of care usually applied on deployments but which were essential in this context: triage, damage control, and management of massive influx of injured. The orthopedic surgical activity was then largely represented by heavy and light traumatology with debridement, osteosynthesis, amputations, and soft tissue coverage.^14,15

Penetrating injuries are a feature of war injuries. Their frequency in France is much lower than on deployment. Thus, the practitioners of military hospitals must maintain their expertise in this field despite this low frequency. French military practitioners compensate for this hazard with two things. First, they position themselves as experts in penetrating wounds in France and are, therefore, called upon to treat these patients in a privileged manner. Second, they benefit from appropriate initial and further training in the management of these injuries.^8,9

The quality of training for young military orthopedic surgeons is an issue that is constantly evolving.^7–9 The aim is to prepare them for the mixed activity they will be confronted with at the beginning of their career: emergency trauma surgery on deployment and scheduled surgery in France. Many strategies have been implemented in recent years to maintain the minimum skills required for emergency trauma surgery.^7,10–12 The results of this study demonstrate that maintaining effective initial and further training for scheduled surgery is essential. It is important not to neglect this preparation, particularly in the field of sports surgery or RSTS. Beyond the training itself, the maintenance of skills remains a real issue throughout orthopedic surgeons’ careers. The objective remains to offer optimal and complete support to the armed forces in France and on deployment. To this end, surgery scheduled in France is a realistic means of continuous preparation for the trauma surgery that military orthopedic surgeons will have to perform on deployment. Consistent with this, Boudin et al.¹³ have shown the importance of oncological surgery in maintaining surgical skills in austere conditions for military surgeons of all specialities.

A limitation of this study was that it was conducted during the COVID-19 pandemic. This inevitably biased the data compared to previous years. Indeed, there was less trauma but also less scheduled surgery (e.g., sports trauma) due to the confinements and COVID-related activity in military hospitals that were on the front line of this pandemic.

CONCLUSION

Military orthopedic surgeons are more than just trauma surgeons. Their activity for the armed forces is varied and is still mainly composed of programmed surgery. During their training, they must acquire skills in trauma surgery but not neglect their training in programmed surgery. They must also acquire the necessary training in France to enable them to carry out this dual activity in order to guarantee the military the appropriate support.

ACKNOWLEDGMENTS

The authors wish to express their gratitude to all the retired orthopedic surgeons who answered to our study.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflicts of interest.

DATA AVAILABILITY STATEMENT

None declared.

ETHICAL APPROVAL AND CONSENT TO PARTICIPATE

Obtained before inclusion. This study was approved by the Chair of Applied Surgery for The French Armed Forces.

CONSENT FOR PUBLICATION

All authors gave final approval for the version to be submitted.

AUTHORS’ CONTRIBUTIONS

All authors contributed to the acquisition of the data, conceptual design, analyses, or critically reviewing.

REFERENCES