OPTIMIZATION OF RETURN TO DUTY AND OUTCOMES IN MILITARY TRAINING SHOULDER AND KNEE INSTABILITY INJURIES

Background: Disease non-battle injury (DNBI), particularly musculoskeletal injury (MSI), represents the largest healthcare dilemma to the U.S. Armed Services. Shoulder and knee injuries account for two of the top five DNBI diagnoses and since 2010 have led to more than 22,000 surgeries annually to treat instability in active duty Service members. Despite the burden of these MSIs to the U.S. Military, there is no system in place within the Defense Health Agency (DHA) to evaluate the factors affecting return to duty (RTD) or clinical outcomes following treatment of this prevalent and disabling condition. Without such information, military healthcare providers are unable to counsel Service members on expected outcomes and likelihood of RTD and military leaders are unable to accurately assess operational readiness. Additionally, the comparative effectiveness of the strategies used to treat these conditions within the DHA is not well established. This study seeks to address gaps between training-related MSI of the upper/lower extremity and clinical outcomes in order to identify factors that predict successful RTD and define best practices that lead to the optimal clinical outcomes.Objective/Hypothesis: The objective of this study is to identify independent risk factors for RTD, patient reported outcome (PRO), and re-injury following shoulder and knee stabilization through a multicenter military collaboration using a web-based outcomes system. The hypothesis to be tested is that there are modifiable and non-modifiable risk factors that affect Service members RTD, PRO, and re-injury following shoulder/knee stabilization.Specific Aims: (1) To determine independent risk factors (predictors) associated with RTD postoperatively at 6 months and 1 year. (2) To determine risk factors (predictors) associated with validated PRO scores, general health, activity level, and PULHES profile score at 6 months and 1 year postoperatively. (3) To determine the military training-specific independent risk factors of injury and re-injury in Service members undergoing surgical stabilization of the knee or shoulder. (4) To determine the effectiveness (compliance rate and patient satisfaction) of a web-based assessment model used to evaluate postoperative shoulder and knee stabilization outcomes.Study Design: A tri-service orthopaedic research network has been established to collaborate using a standardized, web-based, HIPAA-compliant clinical assessment tool. Validated PRO measures, in addition to standard clinical encounters, will be collected by the members of this network to prospectively record baseline and outcome data. Active duty Service members receiving treatment for military training-induced shoulder and knee instability injuries will be enrolled, and validated general and site-specific PRO will be obtained at the time of presentation and at established post-intervention intervals. Demographic, injury, treatment and training-related information will be collected, and medical readiness will be assessed by evaluation of RTD, physical fitness test scores, physical profile status, and physical evaluation board determination. Modifiable and non-modifiable variables affecting RTD and clinical outcomes will be analyzed to develop metrics that predict RTD, prolonged disability, and/or clinical outcomes. Additionally, disease and injury-specific PRO will be compared to the medical readiness status to determine the outcomes necessary to RTD.Impact: Shoulder and knee instability are among the most common and disabling injuries encountered in a military-training environment, accounting for approximately 2,000,000 days of limited duty per year. The proposed study would directly impact the care of Service members with training-related shoulder and knee injuries by providing evidenced-based injury-specific metrics that predict RTD following stabilization and elucidate the clinical and PRO associated with RTD. While a robust injury and illness surveillance system exists within the DHA, we have yet to implement systems to systematically evaluate RTD and treatment outcomes associated with these injuries. Identification of the risk factors and training characteristics that contribute to prolonged disability and poor outcomes using the proposed methodology will improve military medical readiness and offer a translatable model to enhance research capability across multiple specialties.