Similar rates of reoperation for neuroma after transtibial amputations with and without targeted muscle reinnervation.

Objective: To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR). Design: Retrospective cohort study. Setting: Level I trauma hospital and tertiary military medical center. Patients/Participants: Adult patients undergoing transtibial amputations with and without TMR. Intervention: Transtibial amputation with targeted muscle reinnervation. Main Outcome Measurements: Reoperation for symptomatic neuroma. Results: During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97). Conclusions: Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

A Data-Driven Method to Discriminate Limb Salvage from Other Combat-Related Extremity Trauma.

INTRODUCTION: The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. METHODS: Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. RESULTS: The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. CONCLUSIONS: This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.

Mobility Solutions After a Lower Extremity Fracture and Applicability to Battlefield and Wilderness Medicine.

The potential for delayed evacuation of injured Service members from austere environments highlights the need to develop solutions that can stabilize a wound and enable mobility during these prolonged casualty care (PCC) scenarios. Lower extremity fractures have traditionally been treated by immobilization (splinting) followed by air evacuation - a paradigm not practical in PCC scenarios. In the civilian sector, treatment of extremity injuries sustained during remote recreational activities have similar challenges, particularly when adverse weather or terrain precludes early ground or air rescue. This review examines currently available fracture treatment solutions to include splinting, orthotic devices, and biological interventions and evaluates their feasibility: 1) for prolonged use in austere environments and 2) to enable patient mobilization. This review returned three common types of splints to include: a simple box splint, pneumatic splints, and traction splints. None of these splinting techniques allowed for ambulation. However, fixed facility-based orthotic interventions that include weight-bearing features may be combined with common splinting techniques to improve mobility. Biologically-focused technologies to stabilize a long bone fracture are still in their infancy. Integrating design features across these technologies could generate advanced treatments which would enable mobility, thus maximizing survivability until patient evacuation is feasible.

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review.

INTRODUCTION: Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS: A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA: 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA: non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS: The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION: TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.

Exoskeletal solutions to enable mobility with a lower leg fracture in austere environments.

The treatment and evacuation of people with lower limb fractures in austere environments presents unique challenges that assistive exoskeletal devices could address. In these dangerous situations, independent mobility for the injured can preserve their vital capabilities so that they can safely evacuate and minimize the need for additional personnel to help. This expert view article discusses how different exoskeleton archetypes could provide independent mobility while satisfying the requisite needs for portability, maintainability, durability, and adaptability to be available and useful within austere environments. The authors also discuss areas of development that would enable exoskeletons to operate more effectively in these scenarios as well as preserve the health of the injured limb so that definitive treatment after evacuation will produce better outcomes.

NOVEL HIGH-STRENGTH POLYESTER COMPOSITE SCAFFOLDS FOR BONE REGENERATION.

Repair of critical sized bone defects, particularly in load-bearing areas, is a major clinical problem that requires surgical intervention and implantation of biological or engineered grafts. For load-bearing sites, it is essential to use engineered grafts that have both sufficient mechanical strength and appropriate pore properties to support bone repair and tissue regeneration. Unfortunately, the mechanical properties of such grafts are often compromised due to the creation of pores required to facilitate tissue ingrowth following implantation. To overcome the limitations associated with porous scaffolds and their reduced mechanical strength, we have developed a methodology for creating a solid structure that retains its bulk mechanical properties while also evolving into a porous structure in a biological environment through degradation and erosion. In this study, we utilized polyesters that have been approved by the FDA, including poly (lactic acid) (PLA), poly(glycolic acid) (PGA), their copolymer PLGA (PLGA, with a ratio of 85:15 and 50:50 of PLA:PGA), and poly(caprolactone) (PCL). These polymers and their ceramic composites with tricalcium phosphate (TCP) were compression molded into solid forms, which exhibited mechanical properties with compressive modulus as high as 2745 ± 364 MPa within the range of human trabecular bone and in the lower range of human cortical bone. The use of fast-degrading PLGA (50:50) and PGA as porogens allowed the formation of pores within the solid structures due to their degradation, and the TCP acts as a buffering agent to neutralize their acidic degradation byproducts. These scaffolds facilitated the growth of new blood vessels and tissue ingrowth in a subcutaneous implantation model. In addition, in a rat critical-sized mandibular bone defects these scaffolds supported bone growth with 70% of new bone volume fraction. Furthermore, the extent of bone regeneration was found to be higher for the scaffolds with bone morphogenic proteins (BMP2), indicating their suitability for bone repair and regeneration.

Fibrin-Associated Diffuse Large B Cell Lymphoma Found on Revision Arthroplasty of the Knee.

Fibrin-associated diffuse large B cell lymphoma (FA-DLBCL) is a rare Epstein-Barr viruspositive B cell lymphoma that is nonmass-forming, does not directly produce symptoms, and is incidentally discovered on histological examination of tissues excised for other reasons. Despite overlap in morphologic and immunophenotypic features with aggressive B cell neoplasms, FA-DLBCL shows an excellent clinical outcome, even with surgical excision alone. We report an extremely rare occurrence of FA-DLBCL found in association with a metallic implant on revision arthroplasty of the knee. This report also illustrates the need for an integrated multidisciplinary approach for accurate diagnosis and avoidance of overtreatment.

Methylene blue enhances polyethylene glycol-fusion repair of completely severed rat sciatic nerves.

Complete transection of peripheral mixed nerves immediately produces loss of sensory perception, muscle contractions and voluntary behavior mediated by the severed distal axons. In contrast to natural regeneration (~1 mm/d) of proximal axons that may eventually reinnervate denervated targets, re-innervation is restored within minutes by PEG-fusion that consists of neurorrhaphy and a sequence of well specified hypo- and isotonic calcium-free or calcium-containing solutions, the anti-oxidant methylene blue (MB) and the membrane fusogen polyethylene glycol (PEG). In this study, we examined the relative efficacy of PEG-fusion with no MB (0%), 0.5% MB, or 1% MB on the recovery of voluntary behaviors by female Sprague-Dawley rats with a complete mid-thigh severance of their sciatic nerve bathed in extracellular fluid or calcium-containing isotonic saline. The recovery of voluntary behaviors is the most relevant measure of success of any technique to repair peripheral nerve injuries. We assessed recovery by the sciatic functional index, a commonly used measure of voluntary hindlimb behaviors following complete sciatic transections. We reported that both 1% MB and 0.5% MB in sterile distilled water in our PEG-fusion protocol with neurorrhaphy significantly increased the rate and extent of behavioral recovery compared to PEG plus neurorrhaphy alone. Furthermore, 0.5% MB was as effective as 1% MB in voluntary behavioral recovery as assessed by the sciatic functional index. Since sterile 1% MB is no longer clinically available, we therefore recommend that 0.5% MB be included in upcoming human clinical trials to evaluate the safety and efficacy of PEG-fusion. All animal procedures were approved by the University of Texas Institutional Animal Care and Use Committee (AUP-2019-00225) on September 9, 2020.

Desmoid-type fibromatosis of the lower extremity: A unique case of complete lesion resolution following core needle biopsy.

Desmoid-type fibromatosis (DF) is a rare neoplasm characterized by fibroblastic and myofibroblastic proliferation. While characterized as a benign lesion that does not metastasize, desmoid-type fibromatosis exhibits a wide range of behavior from aggressive local tissue invasion and post-surgical recurrence to spontaneous regression. Tumor regression can occur following systemic medical therapy or rarely may occur in the absence of therapy. We present a case of a 50-year-old female with a left thigh vastus medialis intramuscular mass which underwent imaging work-up and subsequent core needle ultrasound-guided biopsy showing results of desmoid-type fibromatosis. Following biopsy, the tumor showed prompt, complete regression with complete MRI resolution 2 months following biopsy. The patient showed no evidence of disease recurrence out to one year on MRI surveillance. This case report will discuss desmoid-type fibromatosis imaging features, treatment strategies, spectrum of disease behavior, and atypical behavior such as the spontaneous tumor regression as seen in this case report. To our knowledge there have been no reported cases of DF spontaneous regression 2 months following a core needle biopsy. Understanding the variable behavior of desmoid-type fibromatosis can assist the radiologist in guiding management of these lesions with the goal of optimizing clinical outcomes and preventing unnecessary aggressive treatments for stable or regressing disease.

Synovial Sarcoma: A Series of Small Tumors in Active Duty Service Members.

Synovial Sarcoma is a soft tissue sarcoma with a propensity to imitate a benign neoplasm. It is most common in males 15-40 years old, typically presents as a slow growing painful mass, and often arises insidiously without alarm to the patient. Three patients with synovial sarcomas who had each undergone an index procedure to treat a small presumedly benign mass that was later identified as synovial sarcoma were reviewed. All three patients required re-excision of the tumor and tumor bed and are currently undergoing routine surveillance. All patients exhibited the classic translocation t(X;18) (p11.2; q11.2) and all were of the monophasic type. All lesions were less than 35 mm in greatest longitudinal dimension on MRI. None have experienced recurrences of synovial sarcoma to date. Healthcare providers should be aware of the synovial sarcoma's propensity to masquerade as a benign disease and the characteristic clinical and radiological findings. We advocate for a low threshold to obtain advanced imaging and consideration of a tissue diagnosis prior to excision. A referral to an orthopedic oncologist should be considered and biopsy should only be performed where the definitive treatment will take place if malignancy is identified.

Venovenous bypass using continuous renal replacement therapy and endovascular inferior vena cava reconstruction to treat bilateral massive iliocaval deep venous thrombosis.

Many inferior vena cava (IVC) anomalies remain asymptomatic because of collateral circulation, but thrombosis of these channels can cause acute deep venous thrombosis with serious sequelae. For those with threatened limbs, anticoagulation is the mainstay of treatment, with endovascular pharmacomechanical thrombolysis replacing open surgical thrombectomy. Described is a severe case of massive iliocaval deep venous thrombosis with bilateral lower extremity Rutherford IIb acute limb ischemia in a patient with congenital IVC atresia. After initial thrombolysis, endovascular IVC reconstruction was accomplished to decompress the lower extremities. The patient ultimately required a right through-knee amputation but remains ambulatory with a prosthetic.

Corrigendum to "Bilateral Proximal Tibia Stress Fractures through Persistent Physes".

[This corrects the article DOI: 10.1155/2018/8181547.].

Upper Extremity Amputation and Prosthetics Care Across the Active Duty Military and Veteran Populations.

The hand and arm are exceptionally dexterous, exquisitely sensitive, and proficient in performing tasks and functions. Given the invaluable functions of the upper extremity in daily life, replacement of a missing limb through prosthetic substitution is challenging. Prosthetic and rehabilitation needs of injured Service members from recent military conflicts have brought upper extremity amputation to the forefront, which has led to an increase in attention and resource allocation. This article provides an overview of the care of the upper extremity amputee including surgical considerations, prosthetic design and fitting, and preprosthetic and post-prosthetic rehabilitation considerations.

Bilateral Proximal Tibia Stress Fractures through Persistent Physes.

INTRODUCTION: Fatigue fractures are stress fractures resulting from repetitive trauma in areas of stress concentration. Prior case reports and studies have described stress fractures through persistent physes about the olecranon and distal fibula, as evidenced by hyaline cartilage on histologic analysis. However, there have been no documented proximal tibia stress fractures through persistent physes. CASE PRESENTATION: A 29-year-old military male basic trainee with varus alignment about his knees suffered bilateral medial tibial plateau stress fractures several weeks into military basic training. He underwent radiographic and laboratory evaluation of his stress fractures and eventual operative fixation of his bilateral tibial plateau fractures. Intraoperative specimens obtained from the fracture sites distal to the articular surface demonstrated abnormal fibrous appearing tissue. Histology demonstrated the presence of hyaline cartilage. DISCUSSION: A 29-year-old military male basic trainee had bilateral proximal tibia stress fractures through persistent physes confirmed with biopsies demonstrating hyaline cartilage. Our belief is that the patient's persistent physes placed him at a greater risk for stress fractures and these may benefit from fixation in soldiers and athletes.

Novel Pseudomonas fluorescens septic sacroiliitis in a healthy soldier.

Septic sacroiliitis is an uncommon infection of immunocompetent patients, typically caused by gram-positive bacteria, with fewer gram-negative cases, and only 5% attributed to Pseudomonas species. We present a healthy soldier with the first reported case of Pseudomonas fluorescens septic sacroiliitis and discuss unique diagnostic and management issues. Because of its rare incidence and nonspecific presentation, septic sacroiliitis is often unrecognized, and its diagnosis is often delayed. Increased awareness of septic sacroiliitis as a potential disease process in the differential diagnosis of troops presenting with a combination of fever, low-back pain, and weight-bearing difficulty is important. As the young age and trauma exposure of the military population represent a prime demographic for this often unrecognized infection, delayed diagnosis can negatively impact a soldier's military readiness. P. fluorescens is itself a rare pathogen and often misidentified in the laboratory. Enhanced microbiological diagnostic techniques beyond routine culture and susceptibility testing should also be considered to account for less commonly seen pathogens. Although optimal antimicrobial treatment duration for infectious sacroiliitis is not well established, this case shows the early efficacy of oral antibiotics.

Greater trochanteric fracture with occult intertrochanteric extension.

Proximal femoral fractures are frequently encountered in the emergency department (ED). Prompt diagnosis is paramount as delay will exacerbate the already poor outcomes associated with these injuries. In cases where radiography is negative but clinical suspicion remains high, magnetic resonance imaging (MRI) is the study of choice as it has the capability to depict fractures which are occult on other imaging modalities. Awareness of a particular subset of proximal femoral fractures, namely greater trochanteric fractures, is vital for both radiologists and clinicians since it has been well documented that they invariably have an intertrochanteric component which may require surgical management. The detection of intertrochanteric or cervical extension of greater trochanteric fractures has been described utilizing MRI but is underestimated with both computed tomography (CT) and bone scan. Therefore, if MRI is unavailable or contraindicated, the diagnosis of an isolated greater trochanteric fracture should be met with caution. The importance of avoiding this potential pitfall is demonstrated in the following case of an elderly woman with hip pain and CT demonstrating an isolated greater trochanteric fracture who subsequently returned to the ED with a displaced intertrochanteric fracture.