Submuscular bridge plating for complex pediatric femur fractures is reliable.

BACKGROUND: Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. QUESTIONS/PURPOSES: We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. METHODS: We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). RESULTS: All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. CONCLUSIONS: SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.

Characterization of the incidence and risk factors for the development of lumbar radiculopathy.

STUDY DESIGN: Epidemiological study of a prospectively collected database. OBJECTIVES: This investigation sought to evaluate the incidence of symptomatic lumbar radiculopathy, and identify risk factors for its development, among individuals serving in the United States military over a 10-year period. SUMMARY OF BACKGROUND DATA: Risk factors for the development of lumbar radiculopathy are poorly understood and the incidence of this disorder has not been characterized earlier for a young, high-demand population. METHODS: The Defense Medical Epidemiology Database was queried for the years 2000 to 2009 using the International Classification of Diseases ninth revision code for lumbar radiculopathy (724.4). Overall incidence was determined and multivariate Poisson regression analysis was carried out to identify the influence of risk factors such as age, sex, race, military rank, and branch of service on the development of this condition. RESULTS: In this population, the overall incidence of lumbar radiculopathy was 4.86 per 1000 person-years. Multivariate Poisson regression analysis showed that female sex, white race, senior positions within the rank structure, and service in the Army, Navy, or Air Force increased the risk of developing lumbar radiculopathy. Servicemembers of 30 years and older were found to have >3 times the risk of developing lumbar radiculopathy when compared with individuals <20. CONCLUSIONS: The incidence of lumbar radiculopathy in this young, racially diverse, and physically active population is higher than many other degenerative conditions. In this study female sex and white race increased the risk of developing lumbar radiculopathy. However, increasing age seems to be one of the most significant independent factors for developing this disorder. LEVEL OF EVIDENCE: Level II, prognostic study.

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.

Occupational outcomes following combat-related gunshot injury: Cohort study.

BACKGROUND: The long-term impact of gun violence on physical function and occupational disability remains poorly explored. We sought to examine the effect of combat-related gunshot injury on work capacity within a cohort of military servicemembers and identify clinical characteristics that influence the capacity to return to work. METHODS: A query was performed to identify all servicemembers injured by gunshot in the years 2005-2009. These soldiers were then followed for a period up to the end of 2014 in order to identify those separated from service due to an inability to perform military duties as a result of their injury. Socio-demographic and clinical characteristics were considered co-variates. The dependent variable in this study was inability to effectively return to work, as delineated by the proxy of medical separation from military service. A multivariable logistic regression model was used to evaluate factors associated with an increased likelihood of medical separation following gunshot injury. RESULTS: Of the 1417 individuals meeting inclusion criteria, 40% (n = 572) of the cohort were medically separated in the time-period under study. Significant predictors of separation included non-thoracic injuries, increased injury severity score (ISS; OR 1.05; 95% CI 1.04, 1.06), Senior Enlisted (OR 3.90; 95% CI 2.16, 7.01), and Junior Enlisted military rank (OR 6.99; 95% CI 3.93, 12.44). CONCLUSIONS: This is the largest study in the literature to assess the long-term capacity to return to work following gunshot injury in any population. Individuals in high-demand occupations and those with non-thoracic wounds, or elevated ISS, should be counseled in the post-gunshot injury period regarding the negative associations of these characteristics with the capacity to return to work. Enhanced access to social services in the period following injury could similarly benefit individuals of low socioeconomic background.

Success of High Tibial Osteotomy in the United States Military.

BACKGROUND: Historically, high tibial osteotomy (HTO) has been performed to treat isolated medial gonarthrosis with varus deformity. PURPOSE: To evaluate the occupational outcomes of HTO in a high-demand military cohort. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective analysis of active duty service members undergoing HTO for coronal plane malalignment and/or intra-articular pathology was performed using the Military Health System between 2003 and 2011. Demographic parameters and surgical variables, including rates of perioperative complications, secondary surgery, activity limitations, and medical discharge, were extracted from electronic medical records. For the current study, cumulative failure was defined as conversion to knee arthroplasty or postoperative medical discharge for persistent knee dysfunction. Univariate and multivariate analyses were performed to identify statistical associations with cumulative failure after HTO. RESULTS: A total of 181 service members (202 HTOs) were identified at an average follow-up of 47.5 months (range, 24-96 months). Mean age was 35.7 years (range, 19-55 years), and the majority were men (93%) and of enlisted rank (78%). All index procedures utilized a valgus-producing, opening wedge technique. Concomitant or staged procedures were performed in 87 patients (48%), including 40 ligamentous, 48 meniscal, and 48 chondral procedures. Complications occurred in 19.3% of knees (n = 39), with unplanned reoperation in 26 knees (12.8%). Fifty-three patients (40.7%) had minor activity limitations during military duty postoperatively. Eleven knees (5.4%) underwent conversion to total knee arthroplasty. The cumulative failure rate was 28.2% (n = 51) at 2- to 8-year follow-up. Patient age younger than 30 years at the time of surgery was associated with an independently higher risk of failure, whereas sex, concomitant/staged procedures, and perioperative complications were not significantly associated with subsequent failure. CONCLUSION: At short- to midterm follow-up, nearly 72% of all service members undergoing HTO returned to military duty and were free from conversion knee arthroplasty.

How people explain actions performed by groups and individuals.

The authors explore whether people explain intentional actions performed by groups differently from actions performed by individuals, A theoretical framework is offered that distinguishes between 2 modes of explanation: the agent's reasons (beliefs or desires in light of which the agent decided to act) and causal histories of reasons (CHRs; factors that preceded and brought about the agent's reasons). The authors develop the hypothesis that people use more CHR explanations when explaining group actions than when explaining individual actions. Study 1 demonstrates this asymmetry. Studies 2 and 3 explore 2 necessary conditions for the asymmetry: that the group be perceived as an aggregate of individual actors rather thin as a jointly acting group and that explainers have general information available about the group. Discussion focuses on people's perception of groups as entities and agents.

Enhanced casualty care from a Global Military Orthopaedic Teleconsultation Program.

BACKGROUND: Since its advent, telemedicine has facilitated access to subspecialty medical care for the treatment of patients in remote and austere settings. The United States military introduced a formal orthopaedic teleconsultation system in 2007, but few reports have explored its scope of practice and efficacy, particularly in a deployed environment during a time of conflict. METHODS: All teleconsultations placed to the orthopaedic service between April 2009 and December 2012 were obtained and retrospectively reviewed. Case files were abstracted and anatomical location of injury, type of injury, origin of consult (country or Navy Afloat), branch of service, and treatment recommendations, were recorded for descriptive analysis. The final result of the consult was also determined, with service members transported from the combat theatre or deployment location defined as medically evacuated. Instances where teleconsultations averted a medical evacuation were also documented as a separate outcome. RESULTS: Over a 32-month period, 597 orthopaedic teleconsultations were placed, with the majority derived from Army (46%) and Navy (32%) personnel deployed in Afghanistan, Iraq, or with Navy Afloat. Approximately 51% of consults involved the upper extremity, including 197 hand injuries, followed by lower extremity (37%) and spine (7.8%) complaints. Fractures comprised over half of all injuries, with the hand and foot most commonly affected. The average response time for teleconsultations was 7.54h. A total of 56 service members required immediate evacuation for further orthopaedic management, while at least 26 medical evacuations were prevented due to the teleconsultation system. CONCLUSIONS: The teleconsultation system promotes early access to orthopaedic subspecialty care in a resource-limited, deployed military setting. The telemedicine network also appears to mitigate unnecessary aeromedical evacuations, reducing healthcare costs, lost duty time, and treatment delays. These findings have important meaning for the future of telemedicine in both the military and civilian setting. LEVEL OF EVIDENCE: IV.

Surgical treatment of chronic exertional compartment syndrome of the leg: failure rates and postoperative disability in an active patient population.

BACKGROUND: Chronic exertional compartment syndrome of the leg is a frequent source of lower-extremity pain in military personnel, competitive athletes, and runners. We are not aware of any previous study in which the authors rigorously evaluated the rates of return to full activity, persistent disability, and surgical revision after operative management of chronic exertional compartment syndrome of the leg in a large, physically active population. METHODS: Individuals who had undergone surgical fasciotomy of the anterior, lateral, and/or posterior compartments (current procedural terminology [CPT] codes 27600, 27601, and 27602) for nontraumatic compartment syndrome of the lower extremity (International Classification of Diseases, Ninth Revision [ICD-9] code 729.72) between 2003 and 2010 were identified from the Military Health System Management Analysis and Reporting Tool (M2). Demographic variables including age, sex, and rank were extracted, and rates of postoperative complications, activity limitations, and revision surgery or medical discharge were obtained from the electronic medical record and U.S. Army Physical Disability Agency database. RESULTS: A total of 611 patients underwent 754 surgical procedures. The average patient age was 28.0 years, and 91.8% of the patients were male. Of the surgical procedures, 77.4% involved only anterior and lateral compartment releases; 19.4% addressed the anterior, lateral, and posterior compartments; and 2.2% addressed the posterior compartments alone. Symptom recurrence was reported by 44.7% of the patients, and 27.7% were unable to return to full activity. Surgical complications were documented for 15.7% of the patients, 5.9% underwent surgical revision, and 17.3% were referred for medical discharge because of chronic exertional compartment syndrome. Univariate analysis of prognostic factors revealed that surgical failure was associated with bilateral involvement (odds ratio [OR], 1.64), perioperative complications (OR, 2.12), activity limitations (OR, 4.41), and persistence of preoperative symptoms (OR, 8.46). Multivariable analysis confirmed significant associations between surgical failure and perioperative complications (OR, 1.72), activity limitations (OR, 2.23), and persistence of preoperative symptoms (OR, 5.47), whereas other factors were not significantly associated with surgical failure. CONCLUSIONS: Chronic exertional compartment syndrome is a substantial contributor to lower-extremity disability in the military population. Nearly half of all service members undergoing fasciotomy reported persistent symptoms, and one in five individuals had unsuccessful surgical treatment.

Spinal injuries in United States military personnel deployed to Iraq and Afghanistan: an epidemiological investigation involving 7877 combat casualties from 2005 to 2009.

STUDY DESIGN: Retrospective analysis of a prospective data set. OBJECTIVE: Determine the incidence and epidemiology of combat-related spinal injuries for the wars in Afghanistan and Iraq. SUMMARY OF BACKGROUND DATA: Recent studies have identified a marked increase in the rate of combat-related spine trauma among casualties in Afghanistan and Iraq. Limitations in these previous works, however, limit their capacity for generalization. METHODS: A manual search of casualty records stored in the Department of Defense Trauma Registry was performed for the years 2005 to 2009. Demographic information, nature of spinal wounding, injury mechanism, concomitant injuries, year, and location of injury were recorded for all soldiers identified as having sustained combat-related spine trauma. Incidence rates were constructed by comparing the frequencies of spine casualties against defense manpower deployment data. Multivariate Poisson regression was used to identify statistically significant factors associated with spinal injury. RESULTS: In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000. Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confidence interval: 1.68-2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39-33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confidence interval: 1.55-2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02). CONCLUSION: The incidence of spine trauma in modern warfare exceeds reported rates from earlier conflicts. The study design and population size may enhance the capacity for generalization of our findings. LEVEL OF EVIDENCE: 3.