Supervening Abscess Resulting in Streptococcus pyogenes Toxic Shock Syndrome Complicated by a Recent MRSA Infection in an Active Duty Military Member.

An 18-year-old male active duty US Army service member presented to the emergency department with a lower leg abscess in the region of a previously debrided methicillin-resistant Staphylococcus aureus abscess. After initial presentation, the patient became hypotensive, exhibited signs of renal failure, and developed a diffuse erythematous rash. Streptococcus pyogenes was grown from intraoperative cultures, and he was diagnosed with Streptococcal toxic shock syndrome (STSS). The patient subsequently underwent multiple surgical debridements, intravenous immunoglobulin treatment, and intravenous antibiotic administration. Streptococcal toxic shock syndrome may have a rapid onset and cause a sharp decline in hemodynamic status requiring admission to the intensive care unit. Any source of virulent Streptococcal pyogenes infection can cause STSS, including lower extremity abscesses. Therefore, it is imperative for physicians to recognize systemic involvement of seemingly isolated extremity infections. We encourage a high index of suspicion in treating bacterial abscesses for possible complications, and close monitoring of patient status. This suspicion should be even higher during outbreaks of bacteria that can cause STSS, much like the patient presented here.

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.

Dunning-Kruger Effect Between Self-Peer Ratings of Surgical Performance During a MASCAL Event and Pre-Event Assessed Trauma Procedural Capabilities.

Objectives: The research question asked to what extent do self-rated performance scores of individual surgeons correspond to assessed procedural performance abilities and to peer ratings of procedural performance during a mass casualty (MASCAL) event? Background: Self-assessment using performance rating scales is ubiquitous in surgical education as a proxy for direct measurement of competence. The validity and reliability of self-ratings as competency measures are susceptible to cognitive biases such as Dunning-Kruger effects, which describe how individuals over/underestimate their own performance compared to assessments from independent sources. The ability of surgeons to accurately self-assess their procedural performance remains undetermined. Methods: A purposive sample of military surgeons (N = 13) who collectively cared for trauma patients during a MASCAL event participated in the study. Pre-event performance assessment scores for 32 trauma procedures were compared with post-event self and peer performance ratings using F tests (P < 0.05) and effect sizes (Cohen's d). Results: There were no significant differences between peer ratings and performance assessment scores. There were significant differences between self-ratings and both peer ratings (P < 0.001) and performance assessment scores (P < 0.001). Effect sizes were very large for self to peer rating comparison (Cohen's d = 2.34) and self to performance assessment comparison (Cohen's d = 2.77). Conclusions: The outcomes demonstrate that self-ratings were significantly lower than the independently determined assessment scores for each surgeon, revealing a Dunning-Kruger effect for highly skilled individuals underestimating their abilities. These outcomes underscore the limitations of self-assessment for measuring competence.

Augmented Reality Forward Damage Control Procedures for Nonsurgeons: A Feasibility Demonstration.

INTRODUCTION: This article presents an emerging capability to project damage control procedures far forward for situations where evacuation to a formal surgical team is delayed. Specifically, we demonstrate the plausibility of using a wearable augmented reality (AR) telestration device to guide a nonsurgeon through a damage control procedure. METHODS: A stand-alone, low-profile, commercial-off-the-shelf wearable AR display was utilized by a remotely located surgeon to synchronously guide a nonsurgeon through proximal control of the distal external iliac artery on a surgical manikin. The manikin wound pattern was selected to simulate a rapidly exsanguinating junctional hemorrhage not controllable by nonsurgical means. RESULTS: This capability demonstration displayed successful use of AR technology, telecommunication, and procedural training and guidance in a single test pilot. The assisted physician assistant was able to rapidly control the simulated external iliac artery injury on this model. The telestration system used was commercially available for use with available civilian cell phone, wireless and satellite networks, without the need for dedicated high-speed networks. CONCLUSIONS: A nonsurgeon, using a wearable commercial on-visual-axis telestration system, successfully performed a damage control procedure, demonstrating the plausibility of this approach.

Sliding Hip Screw for Fixation of Fracture Through a Previously Arthrodesed Hip.

Hip arthrodesis is a treatment option for painful chronic hip conditions. Hip fractures through a previously arthrodesed hip are relatively uncommon as indications for hip arthrodesis are rare. The following case reports on the use of a sliding hip screw and a pelvic reconstruction plate to address arthrodesed hip fracture in an 81-year-old man. The use of a dynamic hip screw in this setting gave us a stable fixed-angle construct with compression across the fracture site, and the addition of a trochanteric side plate added to the stability. The dynamic compression plate with limited bone contact was used to neutralize the construct. This case describes the successful treatment of such an injury in a way not previously described in the literature with the intent of giving the orthopaedic traumatologist another method to approach this rare injury.

Patella Fracture in US Servicemember in an Austere Location.

OBJECTIVE: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances.

Infection After Orthopaedic Trauma: Prevention and Treatment.

Trauma to the extremities is disproportionately represented in casualties of recent conflicts, accounting for >50% of injuries sustained during operations in Iraq and Afghanistan. Infectious complications have been reported in >25% of those evacuated for trauma, and 50% of such patients were treated in the intensive care unit (ICU). Osteomyelitis has been reported in 9% (14% of intensive care unit patients), and deep-wound infection in 27% of type III open-tibia fractures. Infections complicating extremity trauma are frequently caused by multidrug-resistant bacteria and have been demonstrated to lead to failure of limb salvage, unplanned operative take-backs, late amputations, and decreased likelihood of returning to duty. Invasive fungal infections of extremities have also presented a unique challenge in combat-injured patients, particularly in those with blast injuries with massive transfusion requirements and high injury severity scores. Infection prevention should begin at the time of injury and, although context-specific depending on the level of care, includes appropriate irrigation, surgical debridement, wound care and coverage, fracture fixation, and antibiotic prophylaxis, in addition to basic infection prevention measures. Clinical practice guidelines to address infection prevention after combat trauma (including extremity infection) were developed in 2007 and revised in 2011, with endorsement from the Surgical Infection Society and the Infectious Disease Society of America. Nevertheless, significant challenges remain, including austere environments of care, multiple transitions of care, and lack of coordinated efforts in prevention. Treatment of established infections is optimally multidisciplinary, particularly when deep wounds, bone, and joints are involved. Surgical debridement of overtly infected or necrotic tissue is necessary, with particularly aggressive margins if invasive fungal infection is suspected. Infected nonunion frequently requires the use of prosthetic materials for fixation, potentiating biofilm formation, and complicating medical therapy. Antibiotic therapy should be targeted at results of deep wound and bone cultures. However, this is complicated by frequent contamination of wounds, requiring differentiation between potential pathogens in terms of their virulence and decreased culture recovery in patient who have frequently received previous antibiotics. Lessons learned in infection prevention and treatment of orthopaedic trauma from combat can serve to inform the care of patients injured in natural disasters and noncombat trauma.

Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To describe the impact of patient demographics, injury-specific factors, and medical co-morbidities on outcomes after hip fracture using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB). METHODS: The 2008 NSP-NTDB was queried to identify patients sustaining hip fractures. Patient demographics, co-morbidities, injury-specific factors, and outcomes (including mortality and complications) were recorded and a national estimate model was developed. Unadjusted differences for risk factors were evaluated using t test/Wald Chi square analyses. Weighted logistic regression and sensitivity analyses were performed to control for all factors in the model. RESULTS: The weighted sample contained 44,419 incidents of hip fracture. The average age was 72.7. Sixty-two percent of the population was female and 80 % was white. The mortality rate was 4.5 % and 12.5 % sustained at least one complication. Seventeen percent of patients who sustained at least one complication died. Dialysis, presenting in shock, cardiac disease, male sex, and ISS were significant predictors of mortality, while dialysis, obesity, cardiac disease, diabetes, and a procedure delay of ≥2 days influenced complications. The major potential modifiable risk factor appears to be time to procedure, which had a significant impact on complications. CONCLUSIONS: This is the first study to postulate predictors of morbidity and mortality following hip fracture in a US national model. While many co-morbidities appear to be influential in predicting outcome, some of the more significant factors include the presence of shock, dialysis, obesity, and time to surgery. LEVEL OF EVIDENCE: Prognostic study, Level II.

Pelvic trauma: What are the predictors of mortality and cardiac, venous thrombo-embolic and infectious complications following injury?

INTRODUCTION: This study sought to determine risk factors that influence mortality, cardiac events, venous thrombo-embolic disease (VTED), and infection following fractures of the pelvis and/or acetabulum. METHODS: The 2008 National Sample Program (NSP) of the National Trauma Databank was queried to identify all patients who sustained pelvic and acetabular fractures. Demographic data, injury-specific and surgical characteristics, and medical co-morbidities were abstracted. The occurrence of in-hospital mortality, cardiac events, VTED and infections were documented. Univariate testing, weighted logistic regression, and sensitivity analyses were performed to identify significant independent predictors of mortality and the complications under study. RESULTS: The NSP contained 41,297 cases of pelvic trauma. In-hospital mortality was documented in 3055 (7%) and one or more complications occurred in 6932 (17%). Cardiac events transpired in 2% of patients, VTED in 4% and infections in 3%. Increasing age, shock, time to procedure, ISS, and GCS were predictive of mortality. Cardiac events were found to be influenced by obesity, diabetes, ISS, GCS, age, and trauma mechanism. VTED was impacted by obesity, history of respiratory disease, male sex, ISS, GCS, medical co-morbidities, and time to procedure. Injuries caused by mechanisms other than blunt trauma, shock, age, ISS, GCS, medical co-morbidities, and time to procedure were associated with infection. CONCLUSIONS: Several important predictors were identified for specific complications and mortality following pelvic trauma. The design of this study may render it more generalisable to American patients with pelvic injuries. LEVEL OF EVIDENCE: II - Prognostic retrospective study of a prospective dataset.

Genomewide molecular and biologic characterization of biomembrane formation adjacent to a methacrylate spacer in the rat femoral segmental defect model.

OBJECTIVES: This study focuses upon the morphologic and molecular features of the layer of cells, termed the "biomembrane," which forms around methacrylate spacers in bone segmental defects. The objective of this research was to assess the biomembrane formed in a novel rodent femoral segmental defect model at 4, 8, and 16 weeks with histologic and molecular studies. METHODS: Following Institutional Animal Care and Use Committee approval, a segmental defect was created in the rat femur and stabilized with the AO LockingRatNail and analyzed at 4, 8, and 16 weeks postsurgery using digital radiologic imaging, morphological and immunohistochemical studies, and genomewide gene expression studies employing microarray analysis. RESULTS: The biomembrane formed around the methacrylate spacer was rich in vasculature, which showed vascular endothelial growth factor immunolocalization. The biomembrane supported development of foci of bone and cartilage within it. Bone morphogenetic protein 2 immunolocalization and gene expression were positive within developing osseous and chondrocyte foci. Microarray analysis showed significant expression of key genes related to bone and cartilage formation and angiogenesis. CONCLUSIONS: This rat bone model was effective in creation of the biomembrane. Bone and cartilage foci were formed within the vascularized biomembrane with associated expression of genes critical for bone and cartilage development/formation and vascularization. The polymethyl methacrylate-induced biomembrane offers an exciting potential solution for segmental defects; the biomembrane, may act as a receptive bed and also serve as a source for mesenchymal stem cells, which could be recruited/directed for the healing process.

The nature and incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009).

OBJECTIVES: This investigation sought to describe orthopaedic wounds sustained by service members deployed to Iraq or Afghanistan from 2005 to 2009. DESIGN: Retrospective review of prospective data. SETTING: : Joint Theater Trauma Registry (JTTR). PATIENTS: The 6092 musculoskeletal casualties contained in the JTTR. INTERVENTION: The JTTR was queried to identify all personnel sustaining musculoskeletal injuries in the period 2005-2009. Demographic information, injury mechanism, and nature of wounds were determined for all individuals. Deployment data for all service members were obtained through the Defense Manpower Data Center and the incidence of orthopaedic injuries and wounding patterns was assessed. MAIN OUTCOME MEASUREMENTS: Pairwise comparisons were made to identify statistically significant differences in incidence, and significant associations, between injury mechanism and injuries/wounding patterns. RESULTS: The JTTR contained data on 6092 musculoskeletal casualties with 17,177 wounds. Seventy-seven percent of all casualties sustained a musculoskeletal wound. The incidence of musculoskeletal combat casualties was 3.06 per 1000 deployed personnel per year, with fractures occurring in 3.41 per 1000 and soft-tissue wounds most commonly encountered (4.04 per 1000). Amputations represented 6% of all combat wounds. Most musculoskeletal wounds were caused by explosive blast (P < 0.001), as were nearly all traumatic amputations. CONCLUSIONS: This study represents the most complete description of the scope of orthopaedic war trauma. It also presents injury-specific incidences that have not previously been described for musculoskeletal combat casualties. Musculoskeletal casualties may occur in 3 of every 1000 personnel deployed per year. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Metaphyseal and diaphyseal chondroblastomas.

OBJECTIVE: Epiphyseal/apophyseal locations are important diagnostic radiological features of chondroblastomas (CB). Although the tumor may secondarily involve the metaphysis, reports of primary metaphyseal or diaphyseal CB without any epiphyseal or apophyseal involvement are exceptionally rare and frequently present as a diagnostic dilemma. The purpose of this study was to present seven cases of pure metaphyseal and/or diaphyseal CB along with a review of pertinent literature. METHODS: A retrospective review of databases at two major referral centers revealed 390 cases of CB between 1960 and 2009. Out of these, seven histologically proven CB cases (1.8%) were found to be radiologically located in metaphysis and/or diaphysis, without involving the epiphysis and/or apophysis, and formed the study cohort. RESULTS: There were four males and three females (age range 2-25 years). Locations included proximal femur (n = 1), distal femur (2), proximal humerus (2), clavicle (1), and proximal radius (1). All lesions showed marginal sclerosis. A periosteal reaction was seen in five cases (71%), cortical expansion in four cases (57%), and chondroid matrix in four cases (57%). A CT (two cases) demonstrated a matrix in both cases. An MR (one case) showed extensive perilesional edema. Bone scan (one case) showed intense uptake. CONCLUSION: Pure metaphyseal and/or diaphyseal CB are exceedingly rare. A presumptive diagnosis may be considered in the appropriate age group in the presence of chondroid matrix, perilesional edema, periosteal reaction, and marginal sclerosis. Regardless of all the diagnostic possibilities, biopsy may still be required. However, knowledge of this entity will help make the final diagnosis and guide the correct treatment.

Preoperative surgical case review program in a community-based, academic medical center: a feasibility study.

OBJECTIVE: To assess the feasibility of applying postoperative objective criteria for preoperative evaluation of scheduled gynecologic cases. STUDY DESIGN: A preoperative evaluation program was introduced in which all surgeons were asked to voluntarily submit a 1-page case summary questionnaire for each elective gynecologic surgical procedure. A committee of departmental peers reviewed each submission for appropriateness of indications and completeness of preoperative evaluation. Cases were evaluated against quality assessment criteria sets created by the American College of Obstetricians and Gynecologists. Reviewed summaries were categorized as either meeting criteria, not meeting criteria but appropriate, not meeting criteria or no pertinent criteria available for the procedure planned. RESULTS: In all, 2,005 elective gynecologic surgical procedures were performed by 70 active surgeons during the 1-year study period; 1,166 procedures (58%) were reported. Of 70 surgeons, 57 reported at least 1 procedure, but only 6 were 100% compliant with their surgical submissions. In total, 1,008 procedures (86% of reported cases) met the criteria or were deemed appropriate by committee review. In 166 instances, additional information was requested from and provided by the surgeon before the case could be adjudicated. CONCLUSION: A voluntary program of preoperative surgical case review for scheduled gynecologic procedures appeared feasible but resulted in only modest initial participation.