Utilization of a Clinic-Based Hand Surgery Procedure Room in the US Military Health System: A Performance Improvement Analysis of Resource Savings and Patient Satisfaction.

PURPOSE: Recent studies examining the implementation of clinic-based procedure rooms (PRs) for wide-awake hand surgery have reported cost reduction, decreased burden on hospital systems, and improved patient satisfaction. This study evaluates other resource savings, primarily time spent by patients in the hospital. METHODS: Thirty-two patients were enrolled in a PR or the operating room group for prospective evaluation. Time spent in the hospital on the day of surgery, several preprocedure appointments, complications, and cost comparisons were evaluated between the two groups. Patient-reported outcomes were also evaluated with postoperative surveys assessing anxiety, pain, and satisfaction. RESULTS: Significant time savings were noted between the groups. The median time spent in the hospital on the day of surgery for the patients in the operating room group was 256 minutes versus 90 minutes for the PR group, a time savings of approximately 3 hours. Eight additional preoperative clinic visits for operating room patients were generated compared with no additional preoperative visits for PR patients. Cost savings for surgeries performed in the clinic-based procedure amounted to $232,411. No postoperative complications were observed in the clinic setting. CONCLUSIONS: Continued utilization of the clinical PR for select hand surgery procedures will reduce the cost and time burdens for procedures while maintaining satisfaction and safety. CLINICAL RELEVANCE: A clinic-based PR for performing minor hand surgeries saves the patient time and ostensibly allows the operating room to be used for more complex surgeries that are not easily amenable to a wide-awake in-clinic procedure.

The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Racial and Gender Diversity of Physicians Accepted to American Military Orthopaedic and Surgical Residencies: An 18-Year Analysis.

Orthopaedic surgery ranks among the least racially and gender diverse medical/surgical specialties. United States military surgeons train in military or military-funded residency positions to care for a markedly diverse population; however, the composition and diversity of these training programs have not been previously assessed. The purpose of this study was to analyze the trends of physician diversity in military orthopaedics in comparison with other surgical specialties over time. Methods: We performed a retrospective cohort study evaluating matriculation into first year of residency training in US military surgical training programs between 2002 and 2020. In total, 9,124 applicants were reviewed. We collected matriculant self-reported race/ethnicity and sex and the medical/specialty program. We considered under-represented minorities as those who reported their race as African American, Indian/Alaskan Native, and Native, other, or who reported ethnicity as Hispanic. We calculated changes in persons accepted to training positions over time and used linear regression to model trends in diversity among orthopaedic matriculating residents when compared with other surgical subspecialities over time. Results: Across all surgical subspecialities, the average change in percent women was 0.94% per year for the study period (p < 0.01). The average annual percent women entering orthopaedic surgery residency programs was 14% for the 18-year study period. Across all surgical subspecialties, the average change for accepted applicants from groups underrepresented in medicine (URiM) was 1.01% per year for the study period (p < 0.01). The average annual percent URiM entering orthopaedic surgery residency programs was 17% for the 18-year study period. The annual change of women and URiM entering military orthopaedic residencies was 0.10% and 1.52%, respectively. Conclusions: Despite statistically significant improvements, recruitment efforts as used to date fall far short of reversing sexual, racial, and ethnic disparities in military orthopaedic residencies. Orthopaedics has a lower representation of both women and physicians with minority backgrounds when compared with many surgical subspecialties. Additional interventions are still necessary to increase diversity for military orthopaedic surgeons.

Incidence and Risk Factors of Acute Patellar Tendon Rupture, Repair Failure, and Return to Activity in the Active-Duty Military Population.

BACKGROUND: Patellar tendon ruptures have a reported incidence of 0.68 per 100,000 person-years in the general population. The epidemiology of surgically treated patellar tendon ruptures in the US military has yet to be reported, which would provide opportunity for identification of risk factors for these otherwise healthy and active patients. PURPOSE: To determine the incidence of patellar tendon rupture in the Military Health System (MHS) population and to analyze demographic patterns, surgical fixation methods, and rerupture rates. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We utilized the MHS Data Repository (MDR) to identity active-duty military servicemembers surgically treated for patellar tendon rupture between 2010 and 2015. Records were reviewed for demographic information, injury characteristics, fixation technique, and occurrence of rerupture. Risk factors for rupture were calculated using Poisson regression based on population counts and demographic data obtained in the MDR. Risk factors for rerupture and return to duty were analyzed via univariate analysis and multivariate regression. RESULTS: A total of 504 operatively treated primary patellar tendon repairs in 483 patients were identified, with an overall incidence of 6 per 100,000 person-years. Mean age was 33.6 years (range, 17-54 years) and 98% of patients were male. Fixation method was 81% bone tunnels and 7% suture anchors, and 12% were unknown. Black race had a higher relative rate ratio for rupture compared with the race categories White (9.21; P < .0001) and Other (3.27; P < .0001). The rupture rate was higher in 35- to 44-year-old patients compared with those aged 18 to 24 years (P < .0001), 25 to 34 years (P < .0001), and 45 to 64 years (P = .004). Return to full previous level of activity occurred in 75.8% of patients, 14.6% returned to activity with limitations, and 9.5% were medically separated. The rerupture rate was 3%. Fixation method, tobacco usage, body mass index, and race were not significant risk factors for rerupture. CONCLUSION: The incidence of patellar tendon rupture in the US military population is substantially higher than has been reported in the civilian population. Among military personnel, men, Black servicemembers, and those aged 35 to 44 years were at highest risk for patellar tendon rupture. Three-quarters of patients were able to return to full activity without limitations. The rerupture rate was low and unaffected by fixation method.

A Yorkshire swine (Sus scrofa domesticus) model for nerve regeneration and ischemia based on the sciatic nerve and femoral artery.

Animal studies are essential to biomedical research and the cornerstone is a reproducible animal model. While there are many reports on rodent peripheral nerve injury models, a large animal model is essential to confirm the effects of nerve regeneration over the longer distances of regeneration required in humans. Swine have long been used as a large animal model for other surgical and biomedical studies. This paper represents a novel neurovascular injury model in the Sus scrofa domesticus swine (American Yorkshire pig). This paper will describe our experience and recommendations with pre-operative, operative and post-operative protocols and our refinements to produce an effective model.

Synchronous Multifocal Necrotizing Fasciitis: A Case Report.

CASE: An immunocompetent 43-year-old man was diagnosed with necrotizing fasciitis of his forearm. Despite receiving appropriate treatment, his clinical condition continued to deteriorate. Further evaluation revealed subsequent proliferation of the infection to multiple noncontiguous areas of the body consistent with a rare condition known as synchronous multifocal necrotizing fasciitis. Prompt identification, followed by serial debridements of all affected areas, ultimately saved the patient's life. CONCLUSION: This unusual multifocal presentation of necrotizing fasciitis can produce diagnostic uncertainty and delay life-saving treatment. Early recognition, followed by prompt treatment, is paramount for reducing morbidity and mortality associated with this devastating infection.