Frequent Sural Nerve Injury with Posterior Approach for Ankle Fracture Fixation.

INTRODUCTION: The purpose of this study was to report the incidence of iatrogenic sural nerve injury in a large, consecutive sample of surgically managed ankle fractures and to identify factors associated with sural nerve injury and subsequent recovery. We hypothesize that a direct posterior approach may be associated with higher risk of iatrogenic sural nerve injury. METHODS: A retrospective cohort study of 265 skeletally mature patients who sustained ankle fractures over a 2-year period was done. All were treated with open reduction and internal fixation of fractured malleoli. Patient, injury, and treatment features were documented. The presence (n = 26, 9.8%) of sural nerve injury and recovery of sural nerve function were noted. RESULTS: All 26 sural nerve injuries were iatrogenic, occurring postoperatively after open reduction and internal fixation. Patients who sustained sural nerve injuries had more ankle fractures secondary to motor vehicle collisions (23.1% versus 9.2%), more associated trimalleolar fractures (69.2% versus 33.9%), and more Orthopaedic Trauma Association/AO 44B3 fractures (57.7% versus 25.1%), all P < 0.05. A posterior approach to the posterior malleolus through the prone position was used in 20.4% of patients. All 26 of the sural nerve injuries (100%) occurred when the patient was placed prone for a posterior approach, P < 0.001. Therefore, 26 of the 54 patients (48%) treated with a posterior approach sustained an iatrogenic sural nerve injury. 62% of patients had full recovery of sural nerve function with no residual numbness, and patients with nerve recovery had fewer associated fracture-dislocations (23.1% versus 100%, P = 0.003). CONCLUSIONS: A posterior approach for posterior malleolus fixation was associated with a 48% iatrogenic sural nerve injury rate, with 62% recovering full function within 6 months of injury. Morbidity of this approach should be considered, and surgeons should be cautious with nerve handling. LEVEL OF EVIDENCE: Level III, Therapeutic.

The Underlying Effects of Celiac Disease and Subsequent Implications on Deployment in the United States Army.

INTRODUCTION: The purpose of this review is to provide an overview of the etiology, pathology, and treatments for celiac disease (CD), as well as to provide context as to how CD impacts the U.S. military. MATERIALS AND METHODS: To conduct this review, the authors surveyed recent epidemiology and immunology literature in order to provide a detailed summary of the current understanding of CD, its diagnosis, and the real-world impacts within the Department of Defense (DoD). RESULTS: We described the gluten proteins and both the immune response in CD. We further describe the underlying genetic risk factors and diagnosis and pathogenesis of the disease and conclude the review with a discussion of how current DoD regulations impact U.S. military readiness. CONCLUSION: Celiac disease (CD) is an autoimmune disorder that results in damage to the small intestine. Ingestion of gluten in a CD patient is usually followed by villous atrophy in the small intestine, often along with other gastrointestinal symptoms. Around 1% of patients diagnosed with CD can experience complications if gluten-free diet is not followed, including intestinal lymphoma and hyposplenism. Therefore, a patient showing possible symptoms should discuss the diagnostic process with their healthcare providers to ensure adequate understanding of serological and genetic tests along with the histological examination of intestinal biopsy. Patients should seek consults with registered dietitians to structure their diets appropriately. Considering the prevalence and incidence of CD and gluten intolerances are increasing, the military should consider providing gluten-free Meals Ready-to-Eat as an option for all service members. Given the retention of service members with CD, subsequent admission of personnel with mild CD that does not affect the duties will allow the DoD access to a growing population of fully capable service members with critical technical skills who are eager to serve the USA.

Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture.

BACKGROUND: Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures. METHODS: A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney U tests. RESULTS: 136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, P < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without (P = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication (P = .02, P = .05, P = .05). Patients with CKD were more likely to undergo unplanned arthrodesis (P = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, P = .026). CONCLUSION: Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD. LEVEL OF EVIDENCE: Level III, retrospective, comparative, prognostic.

Incidence of Posterior Shoulder Instability in the United States Military: Demographic Considerations From a High-Risk Population.

BACKGROUND: Relatively little is known about the true incidence of posterior shoulder instability in the United States. PURPOSE/HYPOTHESIS: The purpose of this study was to characterize the incidence of posterior shoulder instability in the US military population and to examine which characteristics place these patients at highest risk. We hypothesized that the rate of posterior instability in this cohort of patients would be higher than previously reported. STUDY DESIGN: Descriptive epidemiology study. METHODS: All initial cases of posterior shoulder dislocation and subluxation in the Defense Medical Epidemiology Database were screened between 2016 and 2018 using the relevant International Classification of Diseases-Tenth Revision-Clinical Modification codes. Incidences were calculated, and multivariate Poisson regression was used to calculate adjusted rate ratios for the effects of sex, race, age, military service branch, rank, and year. RESULTS: The overall unadjusted incidence was 0.032 per 1000 person-years for posterior dislocations, 0.064 per 1000 person-years for posterior subluxations, and 0.096 per 1000 person-years for all cases of posterior shoulder instability. The total incidence of all shoulder instability was 1.84 per 1000 person-years, with posterior shoulder instability accounting for 5.2% of total cases. For posterior subluxation, significant differences between groups were found in the unadjusted and adjusted rate ratio (ARR) for sex (ARR, 3.31; 95% CI, 1.85-5.93 for men), race (ARR, 0.458; 95% CI, 0.294-0.714 for Black servicemembers and ARR, 0.632; 95% CI, 0.421-0.948 for servicemembers of other race), age (ARR, 3.69; 95% CI, 1.56-8.70 for patients aged 30-34 years), and military service branch (ARR, 0.663; 95% CI, 0.460-0.955 for Air Force servicemembers). For posterior shoulder dislocations, a significant difference was found only between men and women (ARR, 4.55; 95% CI, 1.85-11.2 for men). CONCLUSION: The incidence of posterior shoulder instability among US military personnel is higher than previously reported in the general US population, with a majority of cases due to subluxation. This increased incidence is likely reflective of a young and highly active population along with improvements in awareness and diagnosis of posterior instability in recent years.