OREF Clinical Research Award Given to Navy Orthopedic Surgeon

Captain Dana C. Covey, Medical Corps, U.S. Navy (Ret.) M.D., received the 2026 Orthopaedic Research and Education Foundation (OREF) Clinical Research Award for 30 years of study on the ways team preparation, logistics, and far-forward patient treatment have helped improve outcomes for battlefield musculoskeletal injuries and led to fewer deaths.

The evolution of on-the-field care, including leaner, more mobile surgical teams, improved military vehicular design, and the widespread use of body armor and modern tourniquets has helped contribute to the lowest case fatality rate in history for the Iraq and Afghanistan wars.ⁱ

Approximately 52,143 service members were wounded in the Iraq and Afghanistan wars, the majority of whom sustained musculoskeletal injuries.^ii,iii Numerous interconnected advancements, including enhanced training for battlefield surgeons, improved body armor, surgical advances, early blood transfusions, and rapid medical evacuation, contributed to a 44% reduction in mortality and improved treatment of life-and-limb-threatening musculoskeletal injuries.ⁱ

“We’ve made significant developments in the last several decades to help lower the rate of fatalities from combat injuries,” said Dr. Covey, clinical professor of orthopedic surgery at University of California San Diego, and a surgeon at VA San Diego Healthcare System. “I spent 40 years in the Navy and have been through various conflicts, documenting lessons from each that could be applied to battlefield care. We have endeavored to implement orthopedic recommendations to evolve treatments, leading to increased survivability and improved musculoskeletal outcomes.”

Battlfield Advancements Increase Survivability

Based on the experiences of Dr. Covey and colleagues, as well as ongoing studies and research by others, U.S. military surgical teams made changes to their strategies, systems, and equipment to reduce the extent of combat injuries.

One of the largest improvements was to combat vehicle design. During the Balkans Civil War in the 1990s, lumbar burst fractures with lower extremity injuries were common in vehicle occupants wounded by antitank mines. Those sitting in the vehicle experienced an axial spinal load transmitted by the vehicle as it accelerated upward from a blast, resulting in anterior and posterior compression failure of the vertebral body.^iv Subsequent studies showed that changing the vehicle design from a flat bottom to a V-hull could significantly reduce fatalities and orthopedic injury rates from under-vehicle explosions.^v This design modification was implemented for the Iraq and Afghanistan wars and is still in use today.

In Afghanistan in 2011, the Pelvic Protection System (PPS)—a two-tiered system of personal pelvic and junctional (transition points) protection—was introduced to reduce blast trauma severity in soldiers. In a study by Dr. Covey, 36 service members who sustained at least one traumatic above-knee amputation in Afghanistan and wore the PPS experienced significantly fewer (p=0.012) junctional/perineal injuries.^vi

To better prepare deploying surgical personnel, teams underwent training that simulated real-world conditions. Covey led a prospective study of 51 military patients who elected to undergo ambulatory surgery in a modified field surgical hospital with an environment and equipment that mirrored the battlefield. The training proved to be valuable. At the two-year follow-up, no patients experienced anesthetic, bleeding, infectious, or other significant perioperative complications.^vii To further this training, Dr. Covey and colleagues from each service presented battlefield information at the inaugural Extremity War Injuries Symposium in 2006 to showcase best practices for state-of-the-art care for patients with combat trauma and prepare military orthopedic surgeons to treat battlefield injuries.

Innovation in On-Field, Off-Field Treatments and Practices Saves Limbs and Lives

The widespread use of modern tourniquets to treat extremity wounds has made a large impact on soldiers’ survival in combat. A study of 232 Iraq war injuries found that tourniquet use was strongly associated with survival (90% vs. 10%; p<0.001).^viii A prospective study by Dr. Covey and Christopher E. Gentchos, M.D., an orthopedic surgeon at Concord Hospital in Concord, N.H., during the Iraq War showed that tourniquets applied for penetrating injuries with severe bleeding reduced transfusion requirements and helped maintain adequate blood pressure.^ix Those with effective tourniquets had less hemorrhage from penetrating orthopedic injuries (p=0.001) and significantly higher mean systolic and diastolic blood pressures. These findings supported another study that showed increased tourniquet use helped reduce mortality.

“The use of tourniquets to treat combat injuries has been a major advancement,” Dr. Covey stated. “All the troops now carry a Combat Action Tourniquet, which can be applied with one hand if someone has an injured limb on the battlefield. The standardization of instrumentation across the different services has helped a lot and has been a key learning from previous conflicts.”

In the 1990s, surgeons began an approach called damage control surgery (DCS) to treat civilian patients with traumatic injuries to limit initial operative interventions for unstable patients until they can improve and withstand prolonged surgery. This approach led to damage-control orthopedics (DCO), which minimizes stress on the body by quickly stabilizing fractures, followed by physiologic optimization, before patients undergo definitive reconstruction, rather than pursuing urgent, definitive orthopedic surgery, as evidence has shown an increase in complications among critically ill patients.^x

Utilizing DCO, complications can be reduced by preventing multisystem organ failure and acute respiratory distress syndrome through immediate hemorrhage control, permissive hypotension, and urgent surgical treatment, including rapid provisional fracture stabilization to prevent the dangerous triad of coagulopathy, hypothermia, and acidosis (too much acid in body fluids).^xi Rapid medical evacuation to a facility that can provide a higher level of intensive care follows to stabilize patients’ vitals before further orthopedic surgery. DCO has become the model for treating patients with severe combat trauma.

“One of the most important aspects of multi-disciplinary research is that we’ve been able to increase the survivability of combat patients and we have improved orthopedic outcomes through expert care early on, setting the stage for a better definitive surgery down the line with better functional outcomes,” Dr. Covey explained. “The advancements in body armor have increased service members’ chances for survival. In previous conflicts, such as in Vietnam, vests that were worn could stop fragments and some low-velocity gunshot wounds. However, the newer body armor worn in the Iraq and Afghanistan wars can protect against higher-velocity bullets and fragments, and has made a marked difference in terms of survivability.”

There have been advancements in caring for combat veterans with orthopedic injuries once they return home. New techniques for the fixation of open, comminuted, battlefield fractures having large zones of injury and soft-tissue loss are being developed. Recent progress in surgery for brachial plexus injuries has improved the previously poor prognosis for those sustaining combat-related brachial plexus wounds. Enhanced data collection of musculoskeletal injuries sustained in combat will help guide future treatment decisions. Challenges continue past the acute care phase of battlefield orthopedic trauma, with many patients requiring rehabilitation and post-acute services, such as mental healthcare, to optimize recovery and reintegration back into military service and everyday life.

“I’ve seen many veterans in my practice and peer support has been shown to be extremely important for wounded warriors, especially amputees,” Dr. Covey concluded. “Peer support helps veterans get through the trauma and rehabilitation phases.”

With more than 39,000 members, AAOS is the world’s largest medical association of musculoskeletal specialists. The organization advances musculoskeletal health by providing comprehensive education to help orthopedic surgeons and allied health professionals best treat patients in their daily practices. AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.

References
ⁱ Howard, JT, Kotwal RS, Stern CA, et al. 2019. Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017. JAMA Surgery. 154(7):600-8.
ⁱⁱ U.S. Department of Defense. Casualty Status. https://www.defense.gov/casualty.pdf. Published Jan. 30, 2025. Accessed Jan. 12, 2026.
ⁱⁱⁱ Owens, BD, Kragh JF, Wenke JC, et al. 2008. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 64(2):295–299.
^iv Covey DC, Lurate RB, Hatton CT. 2000. Field hospital treatment of blast wounds of the musculoskeletal system during the Yugoslav civil war. J Orthop Trauma. 14:278-86.
^v Ramasamy A, Hill AM, Masourosa SD, 2011. Evaluating the effect of vehicle modification in reducing injuries from landmine blasts. An analysis of 2212 incidents and its application for humanitarian purposes. Accident Anal Prevent. 43: 1878– 1886.
^vi Covey DC. 2023. Decreasing lower extremity junctional and perineal injury from explosive blast with a pelvic protection system. Injury. 54(7):110784.
^vii Tounzon J. 2012. NMCSD debuts bioskills training center. Navy Marine Corps Med News. 2012; May:8.
^viii Kragh JF Jr, Walters TJ, Baer DG, et al. 2009. Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 249(1):1-7.
^ix Covey DC, Gentchos CE. 2022. Field tourniquets in an austere military environment: A prospective case series. Injury. 53(10):3240-7.
^x Mathieu L, Bazile F, Barthélémy R, et al. 2011. Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers. Orthop Traumatol Surg Res. 97(8):852-9.
^xi Stevens NM Tejwani NC. 2024 Damage-control orthopedics or early total care: What you need to know. J Trauma. 96(5):694-701.