DOD, VA Doctors Share Latest Advances for Amputees Published July 11, 2014 By Beth Schwinn Health.mil WASHINGTON -- As hundreds of warfighters with amputations return to civilian life, health care providers for both active-duty and retired service members are joining forces to ensure high-quality care for them as well as continued rapid progress in transplant and prosthetic technology. Leading experts from the departments of Defense and Veterans Affairs are sharing discoveries and best practices in caring for service members who have lost limbs at a three-day symposium that begins July 8 in Arlington, Virginia. "A greater percentage of warfighters with multiple amputations have survived [the recent wars] than any other conflict we've ever had," said Dr. Joseph Webster, national medical director for the VA's amputation system of care. A total of 1,646 warfighters lost limbs as a result of the conflicts in Iraq and Afghanistan, and 30 percent of them lost more than one, Webster said. Doctors and therapists now must figure out how to provide lifelong care for these service members, most still in their 20s and 30s. "We really don't know what their needs are. It's going to require continued collaboration," said Webster, who has treated service members with amputations for 20 years. Gatherings like this one help because they "bring together providers who have developed quite a bit of expertise." While few would claim war is good, it unquestionably spurs innovations in medical care and treatment. Previous wars brought emergency rooms and shock trauma units to the civilian world. Among the top medical achievements from the most recent conflicts are advances in limb transplants and prosthetic devices. Also speaking at the symposium are physical and occupational therapists who assist in the challenging rehabilitation process. Nearly 50 doctors and therapists from the VA and at least 35 from the Military Health System are expected to attend. Webster plans to talk about an implant that enables a prosthetic to be attached directly to the bone from the side of the leg or arm, called an osseointegrated implant. The device, now undergoing a clinical trial, is already in use in Europe. The American version fits into the inside of the bone in a manner similar to a total joint replacement, Webster said. Army Lt. Col. Benjamin Kyle Potter, M.D., director of musculoskeletal oncology and orthopedic research at Walter Reed National Medical Center, plans to discuss a kind of rogue bone growth that sometimes occurs in amputees, called combat-related heterotopic ossification. Heterotopic ossification, when the body gets its signals mixed up and bone cells begin to create bone in other tissue, has puzzled doctors for decades. He said the symposium is a great place to share his research on how to better understand, predict and treat or prevent the ossification. "It's crucial to get the care providers and thought leaders in both the DoD and VA together to have an informative discussion about critical issues, where we are now, and recent developments and advances in amputee care," Potter said. Among those discussing limb transplants is Dr. W. P. Andrew Lee, chief of the plastic and reconstructive surgery department at Johns Hopkins School of Medicine, who performed a double-hand transplant on former Army Sgt. Brendan Marocco in 2012. It was the first done on a service member and remains the most extensive arm and hand transplant in the United States to date -- past the elbow on one arm. The transplants involved connecting bones, blood vessels, muscles, tendons, nerves and skin on both arms. To reduce the threat of rejection, the team also transplanted some of the donor's bone marrow. Lee's team has performed seven hand transplant surgeries, more than any other in the United States, and he believes they have the potential to benefit many more warfighters. "A hand and arm transplant can truly transform someone's life," Lee said. "In the right patient, it can deliver motor function and feeling [in the arm and hand] that cannot be achieved with prosthetics." Lee will also describe how, when a transplant is not possible, he reroutes the nerves in a patient's arm to better manage a prosthetic, a process called targeted muscle reinnervation. The same process of reinnervation can help amputees overcome pain in their remaining limbs caused by nerve damage, said Navy Cmdr. George Nanos, M.D., who will be speaking on the topic. Nanos is an expert in the treatment of upper-extremity combat injuries at Walter Reed National Military Medical Center in Bethesda, Maryland. The field of prosthetics has also seen huge advances over the past half-decade. Designs for robotic hands and arms have proliferated. At the symposium, two efforts will be reviewed that are funded by the Defense Advanced Research Projects Agency's Biological Technologies Office, which is led by Col. Geoffrey Ling, a retired Army doctor who served in Iraq and Afghanistan. The DEKA arm system, which has just been approved for commercial development by the Food and Drug Administration, has already been tested by dozens of former service members at the VA. The arm was nicknamed the "Luke" arm, after the hero of the "Star Wars" movies, by lead developer Dean Kamen, inventor of the Segway. The Luke arm is controlled by muscles in the feet and shoulders, similar to the way that some complex video games are controlled by users waving their arms and legs. The other robotic limb is directed by the same electric impulses the mind sends to control body movement, and aims to duplicate all anatomic details of the arm down to the smallest hand joints, in addition to giving the amputee sensation in the limb. It is being developed by scientists at the Johns Hopkins University Applied Physics Laboratory in Laurel, Maryland. "It's far from being completed, but it's an exciting concept," Lee said.