Dr. Bill Obremskey

Member of Consortium Looking At Extremity Trauma

William T. Obremskey, MD, MPH, knows a little bit about being an orthopaedic patient: He sports a hip replacement, courtesy of his gridiron days at Duke University. After three years of active duty in the U.S. Air Force, Obremskey today is an orthopaedic surgeon who merges his patriotism and his medical expertise to further knowledge on how to better treat orthopaedic war trauma.

“I think it’s important that our soldiers receive the best care possible, and then that same care is transferrable to really significant clinical problems that we see in day-to-day practice at a Level 1 Trauma Center,” said Obremskey, director of Orthopaedic Trauma Resident Education and Clinical Research at Vanderbilt University Medical Center.

That’s why Obremskey leads Vanderbilt’s involvement in the Major Extremity Trauma Research Consortium (METRC), established in September 2009 with funding from the Department of Defense and the Orthopaedic Extremity Trauma Research Program.

METRC (pronounced metric) is a network of clinical centers and one data-coordinating center working together with the U.S. Army Institute of Surgical Research to conduct multi-center clinical research relevant to military orthopaedic trauma. METRC’s goal is to produce the evidence needed to establish treatment guidelines for the optimal care of wounded warriors and ultimately to improve quality-of-life outcomes for both military personnel and civilians who sustain high-energy trauma to the extremities.

“The things that we learn about war trauma will be very applicable to soldiers, as well as applicable to the general population,” Obremskey explained. “The one aspect of the war trauma that is often significantly worse is the soft-tissue injury because of the blast effect from an improvised explosive device or a high-energy AK47 or an injury that is associated with burns.” Soldiers also may suffer injury to multiple extremities, he added.

METRC has been awarded $70 million for 10 different research studies, and the coordinating site is Johns Hopkins School of Public Health, a “neutral territory” because Johns Hopkins doesn’t also have a clinical site in the consortium, Obremskey said. While Vanderbilt is expected to participate as a clinical site for all 10 studies, Obremskey is the principal investigator for two of them.

The first examines bone defects, when the patient suffers holes in the bones. “They have a fracture, but parts of the bone are missing. How to reconstruct that is a challenge. If you can’t reconstruct the bone, then you have to have an amputation,” Obremskey said.

Thus, Vanderbilt is working to determine whether an allograft will work as well in these situations as an autograft. An autograft uses bone donated by the patient from somewhere else in the body. The positive is that there’s a high probability of successful bone fusion when using the patient’s own bone. “But when you have these very large defects or two or three extremity injuries, sometimes there’s just not enough extra bone to go around,” Obremskey explained. “So we’ve been looking at other options.”

The option that Vanderbilt will be exploring is the use of an allograft – bone donated from cadavers – mixed with a bone-growth protein. The FDA-approved trial will be randomized to determine if the allograft-protein mix is a viable alternative for an autograft. The trial is under review by the Institutional Review Boards for the participating sites, and Obremskey anticipates that patient enrollment will begin in the spring.

The second trial Vanderbilt is heading has to do with post-operative infection. Those infections may be caused by several factors: the skin or soft tissue is contused, the bone has broken through the skin, the fracture is open, or it’s an outside-in fracture from a blast or bullet. “There’s the potential for a lot of contamination from the dirt that gets ground into the wounds, and infection has been a big problem with military wounds,” Obremskey said. “It’s also the most common problem we see with severe fractures in the general population.”

Vanderbilt will be working to determine whether oral antibiotics would be just as successful as intravenous antibiotics in suppressing infection until the bone heals. With oral antibiotics, costs are significantly lower, there is less potential for complication and administration of the medication is easier. In the case of the military, those three benefits are compelling. “There’s not great science comparing one versus the other,” said Obremskey, who has seen what an infection can do to someone.

Last year, Obremskey assisted a colleague with an amputation, and the patient suffered from Group A strep, necrotizing fasciitis (commonly known as the flesh-eating disease) and toxic shock syndrome. Obremskey contracted them, too, and for a while it was touch and go. “I got to see the inside of Vanderbilt through and through,” he said. “I amazingly have no deficits, but I’ve certainly been on the other side of the rehabilitation. It’s nothing like our soldiers go through, but you’re taken out of your life and then you start all over again. Appreciating quality care makes a big difference.”

www.vanderbilthealth.com/orthopaedics/

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