Return to Duty in Military Servicemembers After High Tibial Osteotomy Not Associated With Preoperative Radiographic Parameters : A Retrospective Analysis.

Background: Evidence on return to sports/work after high tibial osteotomy (HTO) is limited, especially in a young, high-demand population. Purpose: To (1) identify whether preoperative knee pathology or intraoperative correction was associated with successful return to duty (RTD) and (2) assess whether postoperative complications and reoperation were associated with failure to RTD. Study Design: Case series; Level of Evidence, 4. Methods: We performed a retrospective cohort study of a consecutive series of patients in the Military Health System aged 18 to 55 years with medial compartment osteoarthritis who underwent HTO between 2003 and 2018. Concomitant meniscal and cartilage procedures were included, while cases with concomitant ligamentous procedures were excluded. The inclusion criteria were as follows: active-duty military status, minimum 2-year follow-up, preoperative knee radiographs, and pre- and postoperative long-leg alignment radiographs. Preoperative Kellgren-Lawrence grades and pre- and postoperative hip-knee-ankle angles were measured. The primary outcome was RTD. Failure was defined as knee-related medical separation from the military or conversion to total knee arthroplasty. The secondary outcome was reoperation. Results: A total of 55 HTOs were performed in 50 patients who met the inclusion criteria, with a mean age of 39 years old (range, 22.8-55 years). The mean follow-up was 5 years (range, 2.1-10.7 years). Ten knees (18.2%) failed HTO (1 conversion to total knee arthroplasty, 9 medical separations), 15 additional knees (27.3%) had permanent activity restrictions, and 30 knees (54.5%) returned to duty without restrictions. Reoperation occurred in 36.4% of knees and was associated with medical separation (P = .039). Younger age was associated with medical separation (P = .003) and permanent restrictions (P = .006). Patients with a postoperative varus deformity of >5° were more likely to undergo medical separation (P = .023). Conclusion: In a young, high-demand population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 36.4% of knees requiring reoperation. Residual varus deformity or reoperation was associated with lower RTD rates. No association was identified between RTD and preoperative osteoarthritis grading or deformity.

Most Military Arthroplasty Surgeons Have a Low Volume Practice in the Military Health System.

Background: The purpose of this study is to investigate hospital and surgeon joint arthroplasty volume in the Military Health System (MHS). A secondary aim is to look at interruption in physician practice during the study period. Methods: Review of all patients undergoing hip or knee arthroplasty in the MHS over >5-year period to examine hospital and surgeon volume for total joint arthroplasty (TJA). We stratified hospital and surgeon volume into low, medium, and high volumes. Results: Fifty surgeons performed at least 50 hip and/or knee arthroplasties during this period. These surgeons accounted for 75% of TJA in the MHS. When stratified by cases per year, the median primary total hip arthroplasty (THA) per year was 31.4 and primary total knee arthroplasty (TKA) was 47.3 per year. Regarding the volume threshold for primary and revision TJA, all hospitals were classified as having low volumes for both THA and unicompartmental knee arthroplasty/TKA. There were 0 high volume, 7 (21.9%) medium volume, and 25 (78.1%) low volume THA surgeons; there was 1 high volume TKA surgeon, 17 (34.7%) medium volume, and 31 (63.3%) low volume TKA surgeons. The average duration of clinical activity for fellowship-trained surgeons over the study period was 4.0 years, and the average duration of clinical inactivity was 263.7 days (17.9% of practice period). Conclusions: The highest-volume military arthroplasty surgeons have low volume when compared to their civilian colleagues. There are also long periods of clinical practice interruption. These findings stress the need to establish civilian-DOD or DOD-VA working relationships so that MHS patients experience the best possible care by high-volume surgeons in high-volume surgical centers.

Computed Tomography of the Chest as a Screening Tool for Low Bone Mineral Density.

INTRODUCTION: Computed tomography (CT) Hounsfield units (HU) recently emerged as a promising screening tool for low bone mineral density (BMD). We hypothesized that CT HU measurements of the thoracic spine would significantly and positively correlate with dual X-ray absorptiometry (DXA) BMD scans of the femoral neck. MATERIALS AND METHODS: The study included patients with DXA scans and thoracic CT scans at the Walter Reed National Military Medical Center. One author, blinded to the DXA scans, measured HU from the cancellous bone in T4 vertebrae. Another author statistically compared femoral neck DXA T-scores to the CT HU measurements. RESULTS: The study included 145 patients with CT scans and femoral neck DXAs. The osteoporotic and osteopenic groups had a significant difference in HU measurements compared to the normal group within the study (P < .0001 and .002, respectively). A low BMD screening value of 231 HU provided a sensitivity of 90.1% and negative predictive value of 85.7%. CONCLUSION: Thoracic vertebrae HU measurements correlate with a low BMD of the femoral neck as determined by DXA T-scores. A high sensitivity and negative predictive value was achieved with a screening value of 231 HU. Utilization of chest or thoracic spine CT imaging as a screening method provides a quick and available screening tool for assessing low BMD in patients with these scans.Level of Evidence: III (Diagnostic).

Effects of Spinal Anesthesia in Geriatric Hip Fracture: A Propensity-Matched Study.

OBJECTIVES: To identify whether anesthesia type is associated with surgical outcomes in geriatric patients undergoing operative treatment for a hip fracture. DESIGN: Retrospective database review of prospectively collected data. PATIENTS: Patients included in the American College of Surgeons National Surgical Quality Improvement Program database. All included patients were 65-89 years of age and had a hip fracture treated with internal fixation, arthroplasty, or intramedullary device. Patients were excluded for open, pathologic, stress-related, or periprosthetic hip fractures. INTERVENTION: Use of spinal anesthesia (SA) or general anesthesia (GA). MAIN OUTCOME MEASUREMENTS: Complications, mortality, and discharge destination. RESULTS: A total of 23,649 cases met inclusion and exclusion criteria and were successfully matched using propensity score matching: 15,766 GA and 7883 SA. The odds of sustaining a complication were 21% lower in the SA group compared with those in the GA group (odds ratio SA/GA 0.791; 95% confidence interval, 0.747-0.838). The 30-day mortality rate was not correlated with SA or GA choice. Patients who underwent SA were significantly more likely to be discharged to home (odds ratio SA/GA 1.65; 95% confidence interval, 1.531-1.773). CONCLUSIONS: No mortality difference exists between patients undergoing SA and those undergoing GA for hip fracture surgery. For patients undergoing hip fracture surgery with SA, there is lower 30-day complication profile and higher discharge to home rate compared with those undergoing GA. Both anesthesia modalities may be acceptable. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary Foreign Bodies within Fresh-Frozen Fibular Cortical Allograft: A Case Report.

CASE: A 71-year-old man with a proximal humerus fracture nonunion underwent surgery augmented by a fibular cortical strut allograft. On placing the allograft within the proximal humerus, fluoroscopic images showed 2 foreign bodies found to be broken drill bits located within the allograft. The drill bits were extracted, and the allograft was reprepared for use. CONCLUSION: After 2 years of follow-up, no significant sequela related to the foreign bodies was noted. To the best of our knowledge, this case report represents the first-of-its-kind occurrence of broken drill bits found within bone allograft.

Unicompartmental Knee Arthroplasty: More Conversions, Fewer Complications Than Proximal Tibial Osteotomy in a Young Population.

BACKGROUND: Patients with isolated medial compartment osteoarthritis requiring surgical intervention generally have two surgical options: unicompartmental knee arthroplasty (UKA) and proximal tibial osteotomy (PTO). Outcomes of reoperation rates and survivorship are important for counseling patients on treatment options. METHODS: A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent either UKA or PTO between 2003 and 2018. All patients were between 18 and 55 years old and diagnosed with isolated medial compartmental arthritis. Cases with concurrent meniscal or cartilage procedures were included, while cases with concurrent ligament reconstruction were excluded. A minimum 2-year follow-up was required. The primary outcome was conversion to total knee arthroplasty, and the secondary outcome was reoperation for any reason. RESULTS: A total of 383 procedures were performed for isolated medial compartment arthritis in 303 patients (UKA 270, PTO 113). A multivariate analysis showed that PTO was associated with decreased risk of conversion to TKA compared to UKA (P = .0364). However, the reoperation due to complications was significantly higher in the PTO group (21.2% vs 2.2%; P ≤ .01). The 5-year conversion rate was 13.7% for UKA and 3.5% for PTO (P = .0033) with an average time to conversion of 3.1 years for UKA and 2.9 years for PTO (P = .7805). CONCLUSIONS: In young patients with isolated medial compartment arthritis, conversion rates to TKA are higher with UKA compared to PTO. However, overall reoperation rate is higher with PTO, secondary to complications and revision procedures. Overall survivorship is acceptable for both procedures.

Femoral Neck Over-Resection After Hip Arthroscopy Treated with Vascularized Fibula Autograft: A Case Report.

CASE: We describe a case of femoroacetabular impingement syndrome treated with labral repair and arthroscopic femoral osteoplasty in a 30-year-old man. The case was complicated by resection of 50% of the femoral neck resulting in high risk of an impending femoral neck fracture. The patient was treated with a vascularized fibula autograft and internal fixation. CONCLUSION: Complications of femoral neck over-resection can threaten the viability and structural integrity of the hip joint but may successfully be treated with vascularized fibula autograft.

Latarjet After Failed Arthroscopic Bankart Repair Results in Twice the Rate of Recurrent Instability Compared With Primary Latarjet.

PURPOSE: To assess recurrent instability of the shoulder following open Latarjet performed as the primary stabilization procedure or as a salvage procedure. METHODS: A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent open Latarjet from January 1, 2010, to December 31, 2018. All patients were diagnosed with recurrent anterior shoulder instability and had a minimum of 2 years of postoperative follow-up. Patients were categorized as either having a primary Latarjet (PL; no prior shoulder stabilization procedure) or salvage Latarjet (SL; ≥1 previous arthroscopic surgical stabilization procedures). RESULTS: A total of 234 Latarjet procedures were performed in 234 patients. The overall recurrent instability rate was 15.8% (37/234), the overall reoperation rate was 16.7% (36/234), and the overall complication rate was 14.2% (33/234) over a mean 5.0 years of follow-up. There were 99 PL procedures and 135 SL procedures. The SL group had significantly more recurrent instability than the PL group (SL 28/135, 20.7%; PL 9/99, 9.1%; P = .0158). There was no difference in overall reoperation rates (SL 26/135, 19.3%; PL 13/99, 13.1%; P = .2140) or complication rates (SL 20/135, 14.8%; PL 13/99, 13.3%; P = .9101). CONCLUSION: The rate of recurrent instability following the Latarjet procedure in an active, high-risk population is 15.8%. Primary Latarjet was found to have lower rates of recurrence compared with salvage Latarjet procedures (9.1% versus 20.7%). LEVEL OF EVIDENCE: III.

Cervical Spine Computed Tomography Hounsfield Units Accurately Predict Low Bone Mineral Density of the Femoral Neck.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The objective of this study to determine the correlation between Hounsfield unit (HU) measurements from the C4 vertebral body and dual-energy x-ray absorptiometry (DXA) T-score. SUMMARY OF BACKGROUND DATA: Recent attention has turned to the utilization of HU measurements from computed tomography (CT) as a potential screening method for low bone mineral density (BMD). We hypothesized that cervical spine CT HU measurements will correlate with BMD measurements conducted with DXA scans of the femoral neck. MATERIAL AND METHODS: Patients with cervical CT and femoral neck DXA scans at 1 institution were included in the study. HUs were manually measured from the cancellous bone in the C4 vertebrae by 1 author blinded to DXA scans. HU measurements were compared with femoral neck DXA T-scores for the entire population. RESULTS: A total of 149 patients with 149 cervical CT and femoral neck DXA scans were included in the study. The low BMD group (osteoporotic and osteopenic combined) showed a significant difference in HU compared with the normal groups within the study (P<0.0001). A low BMD screening value of 447 HU captured over 95% of patients with low BMD within our study and provided a sensitivity of 92% and negative predictive value of 82.1%. The male and female intrasex analysis demonstrated a significant difference between the low BMD and normal BMD groups with P=0.001 and P=0.0001, respectively. CONCLUSIONS: HU measurements taken from the C4 vertebral body on CT scan correlate with low BMD of the femoral neck as determined by DXA scan T-scores. Screening values of 447 HU captured 95% of patients with low BMD, with a high degree of sensitivity, and negative predictive value of 80%. Utilization of cervical spine HU as a screening method provides a simple, quick, and easily assessable screening tool for assessing low BMD. LEVEL OF EVIDENCE: Level III-diagnostic.

Shaken but prepared: Analysis of disaster response at an academic medical centre following the Boston Marathon bombings.

Over the last decade, there has been a rise in the number of mass casualty incidences (MCIs) and their subsequent effect on hospital systems. While there has been much discussion over improving procedures to treat victims of MCIs, there has not been a thorough, systems-based analysis concerning the costs incurred by hospitals during such events. Here the authors examine the history of the Hospital Incident Command Center and how its evolution at Tufts Medical Center helped mitigate the damage following the Boston Marathon Bombings. Tufts' unique variations to the Hospital Incident Command Center include strategic communication hierarchies and a 'zero cost centre' financial system which both provided for a quick and adaptive response. Operating in collaboration with the Conference of Boston Teaching Hospitals encouraged coordination and preparation during emergency situations such as mass casualty events. The direct and indirect effects on Tufts Medical Center stemming from the Boston Marathon Bombings were analysed. Tufts MC treated 36 victims immediately following the MCI. The estimated total cost during the week of April 15 to April 19, 2013 was $776,051. The cost was primarily comprised of lost revenue from cancelled outpatient and inpatient hospital services, as well as expenses incurred due to overtime pay, salary expenses, PPE kits and hospitality services. Finally, the authors examine ways to reduce the future costs during emergency situations through increasing communication with employees, understanding the source of all direct expenses, and mitigating excess risk by developing partnerships with other hospital systems.