Joint replacements in the Canadian Armed Forces.

SUMMARY: There is currently no consensus on the appropriate sports and occupational restrictions for military service members with a joint replacement. Data from the United States show that 14% of military patients complete an operational deployment after the index surgery. No published data are available on arthroplasty in the militaries of other North Atlantic Treaty Organization countries. Research is needed to determine the appropriate medical employment limitations for Canadian Armed Forces members with a knee or hip replacement. Service members wanting to continue military service should be carefully screened to ensure that their duties do not compromise the longevity of the implant and that the risk of mission-threatening complications is minimal.

A pilot study of surgical telementoring for leg fasciotomy.

INTRODUCTION: Acute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research. METHODS: Three anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications. RESULTS: 14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth. CONCLUSIONS: This study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.

Ultrasound-assisted external fixation: a technique for austere environments.

INTRODUCTION: Ultrasound-assisted external fixation of long bones has the potential to enhance extremity damage control surgery in locations without fluoroscopy, such as forward surgical elements, the intensive care unit, and spacecraft. This pre-clinical study specifically sought to evaluate orthopaedic surgeons' ability to sonographically define fracture patterns and the associated zone of injury in order to improve surgical decision-making and safely insert Schanz pin percutaneously. METHODS: We encased small composite femurs in a cylindrical echogenic gelatin matrix to simulate a human thigh. Three orthopaedic trauma surgeons with no prior ultrasound experience were taught to use sonography to diagnose fractures and assist external fixation. The surgeons were then presented with five specimens in a randomized sequence: three diaphyseal fractures (32-A2, 32-C2 and 32-C3); a distal femur fracture (33-A1.2); and an intact femur, all encased in an opaque black gelatin matrix to blind the participants to the underlying pathology. If they diagnosed a diaphyseal fracture, the surgeons were instructed to insert two Schanz pins proximal and two distal to the fracture, no closer than 40 mm from the fracture edges. RESULTS: Fracture diagnosis and surgical decision-making were correct in all cases. All intact femurs were recognized as such. The need for a knee-spanning external fixator was recognized for all distal femur fractures. The three surgeons performed appropriate ultrasound-assisted pin placement in every case of diaphyseal fracture. The pins adjacent to the fracture site were on average 58 mm (SD ±11 mm) from the edge of the fracture. No pins were inserted in the fracture or in the knee joint. CONCLUSIONS: The current study results suggest that with minimal training, orthopaedic surgeons can use portable ultrasound to diagnose femur fractures, decide the appropriate external fixator configuration, and safely insert Schanz pins outside the zone of injury.

Advances in damage control resuscitation and surgery: implications on the organization of future military field forces.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

De plus en plus, la responsabilité du soutien médical offert aux forces militaires déployées sur le terrain devient partagée entre les nations alliées. Les planificateurs médicaux militaires nationaux font face à plusieurs défis importants, tels que restrictions budgétaires, attentes élevées au chapitre des normes de soin sur le terrain et pénurie de spécialistes dûment formés. Malgré cela, les services médicaux sont présentement en grande demande et leur disponibilité pourrait devenir le facteur limitatif susceptible de déterminer de quelle façon et en quels lieux les unités de combat peuvent se déployer. L'impact des facteurs médicaux sur les décisions opérationnelles requiert donc de plus en plus des solutions médicales multinationales. Les nations doivent s'entendre sur des normes communes qui régissent les soins à prodiguer aux blessés. Ces normes devront toujours tenir compte des attentes accrues du public en regard de la qualité des soins. Le but de cet article est de revoir les politiques de l'Organisation du Traité de l'Atlantique Nord (OTAN) qui régissent les missions médicales multinationales et de discuter de la façon dont les progrès scientifiques récents des soins pré-hospitaliers sur les champs de bataille et les techniques de réanimation et de chirurgie de sauvetage peuvent éclairer la façon dont les pays de l'OTAN décideront d'organiser et de déployer leurs forces sur le terrain à l'avenir.

Are military fitness tests safe for members with a total hip arthroplasty?

INTRODUCTION: Canadian Armed Forces (CAF) members must complete an annual fitness evaluation. Members with a total hip arthroplasty (THA) may be at risk of injury during these strenuous tests. To inform CAF policy, we sought expert consensus on the safety of fitness testing for members with a THA. METHODS: We conducted a three-round Delphi study with a panel of hip arthroplasty experts to determine the safety of CAF operational fitness evaluations for members with a THA. The experts evaluated videos of the 10 individual tasks included in the evaluations. RESULTS: All individual tasks were judged to be safe by consensus. One task, which involves digging with a shovel, was considered safe provided that participants avoid deep hip flexion. The nine other tasks were judged to be safe without modifications or interventions. The experts also supported a policy recommendation that would allow members to perform military fitness evaluations if they (1) have a primary THA, (2) had no episodes of instability, (3) are at least 12 months postoperatively and (4) have been cleared by an orthopaedic surgeon and a physiatrist/physiotherapist. CONCLUSION: A panel of arthroplasty experts concluded, based on video analysis, that CAF fitness evaluations are generally safe for members with a THA.

1 Canadian Field Hospital in Haiti: surgical experience in earthquake relief.

The Canadian Forces' (CF) deployable hospital, 1 Canadian Field Hospital, was deployed to Haiti after an earthquake that caused massive devastation. Two surgical teams performed 167 operations over a 39-day period starting 17 days after the index event. Most operations were unrelated to the earthquake. Replacing or supplementing the destroyed local surgical capacity for a brief period after a disaster can be a valuable contribution to relief efforts. For future humanitarian operations/disaster response missions, the CF will study the feasibility of accelerating the deployment of surgical capabilities.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury.

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care.

BACKGROUND: Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield. METHODS: We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries. RESULTS: Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05). CONCLUSIONS: IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.

Causes of death in Canadian Forces members deployed to Afghanistan and implications on tactical combat casualty care provision.

BACKGROUND: As part of its contribution to the Global War on Terror and North Atlantic Treaty Organization's International Security Assistance Force, the Canadian Forces deployed to Kandahar, Afghanistan, in 2006. We have studied the causes of deaths sustained by the Canadian Forces during the first 28 months of this mission. The purpose of this study was to identify potential areas for improving battlefield trauma care. METHODS: We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, injury data, location of death within the chain of evacuation, and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons. RESULTS: During the study period, 73 Canadian Forces members died in Afghanistan. Their mean age was 29 (+/-7) years and 98% were male. The predominant mechanism of injury was explosive blast, resulting in 81% of overall deaths during the study period. Gunshot wounds and nonblast-related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean Injury Severity Score was 57 (+/-24) for the 63 study patients analyzed. The most common cause of death was hemorrhage (38%), followed by neurologic injury (33%) and blast injuries (16%). Three deaths were deemed potentially preventable on explicit review, but implicit review only categorized two deaths as being potentially preventable. CONCLUSIONS: The majority of combat-related deaths occurred in the field (92%). Very few deaths were potentially preventable with current Tactical Combat Casualty interventions. Our panel review identified several interventions that are not currently part of Tactical Combat Casualty that may prevent future battlefield deaths.

Early resection of ectopic bone in patients with heterotopic ossification about the hip after trauma.

OBJECTIVES: Heterotopic ossification (HO) is a common complication in patients who have sustained high-energy trauma to the hip region. Traditionally, resection is performed after ectopic bone maturation. We hypothesized that early HO resection in patients with hip ankylosis after trauma can be performed with little chance of recurrence. DESIGN: Retrospective clinical cohort. SETTING: Level I Trauma Center PATIENTS/PARTICIPANTS: 14 patients with resection of HO about the hip performed by the senior author during a six-year period. INTERVENTION: Early resection of Brooker Class III or IV HO. MAIN OUTCOME MEASUREMENTS: The original injuries, risk factors for HO, post-traumatic clinical course including the workup for HO, times from fixation to resection, surgical approach, and complications were recorded. Records were reviewed to document pre and postoperative hip motions. Pre and post-operative x-rays and CT scans were reviewed to classify the HO and localize the ectopic mass. RESULTS: Mean injury to resection interval was 6.8-months. Nine of 14 (64%) patients were followed for a mean of 32.9-months post-resection. Indications for resection included pain, stiffness, and evolving sciatic nerve lesions. Risk factors were male gender, brain injury, and extended iliofemoral and Kocher-Langenbeck surgical approaches. Complications included gluteal vein laceration, draining wounds, and recurrence. Mean flexion-extension arc of motion was 18° (range = 0-70°) preoperatively, 100° (range = 85-125°) intra-operatively, and 94° (range = 20-110°) at final follow-up. HO recurred in nine patients; functionally significant in one. CONCLUSION: Early resection of HO around the hip may be performed with little chance of symptomatic recurrence. LEVEL OF EVIDENCE: This is a Level IV retrospective case series.

Effectiveness of Iodophor vs Chlorhexidine Solutions for Surgical Site Infections and Unplanned Reoperations for Patients Who Underwent Fracture Repair: The PREP-IT Master Protocol.

Importance: The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. Objective: To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. Design, Setting, and Participants: The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. Discussion: The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. Trial Registration: ClinicalTrials.gov Identifiers: NCT03385304 and NCT03523962.

Cyclic loading of periprosthetic fracture fixation constructs.

BACKGROUND: Femur fractures are a common complication of hip arthroplasty. When the stem is well fixed, fracture fixation is the preferred treatment option. Numerous fixation methods have been advocated, using plates or allograft struts. METHODS: Vancouver type B1 periprosthetic femur fractures were created distal to a cemented hip stem in 15 third-generation composite femurs. The fractures were fixed with (1) a nonlocking plate and allograft strut, (2) a locking plate and allograft strut, or (3) a locking plate alone. The struts were fixed with cables. After fixation, the constructs underwent cyclic loading for 100,000 cycles. Stiffness of the constructs was determined during bending, torsion, and axial compression before and after cyclic loading. Load to failure was also determined. RESULTS: Overall, cyclic loading had little effect on the mechanical properties of these constructs. The two constructs with allografts were significantly stiffer in bending than the construct consisting of only a locking plate. There were no significant differences in axial or torsional stiffness between the constructs. Load to failure of the two constructs with allografts was significantly greater than the locking plate alone. CONCLUSIONS: Allograft strut-plate constructs are stiffer in bending and have a higher load to failure than a stand-alone locking plate. When an allograft plate construct is chosen, locking screw seemed to provide no mechanical advantage. All three constructs tested retained their mechanical characteristics after 100,000 cycles of loading. Our initial concern that the cables fixing the allograft strut would loosen appears unfounded.

High Bilateral Amputations and Dismounted Complex Blast Injury (DCBI).

High, combat-related bilateral lower extremity amputations rarely occur in isolation. Dismounted complex blast injury is a devastating and life-threatening constellation of multisystem injuries most commonly due to dismounted contact with improvised explosive devices. Rapid damage control resuscitation and surgery are essential to improve patient survival and minimize both early complications and late sequelae. A coordinated team approach is essential to provide simultaneous airway management, volume resuscitation (ideally with whole blood or ratio transfusion), and immediate control of life-threatening hemorrhage. Temporary aortic or iliac vessel clamping during concurrent exploratory or vascular control laparotomy is frequently required. Stabilization of unstable pelvic fractures is then performed, followed by debridement and irrigation of all wounds, which should be left open, and subsequent provisional stabilization of long bone fractures. The goal of the initial surgical resuscitative endeavor is rapid concurrent control of all sources of hemorrhage to avoid the lethal triad of acidosis, hypothermia and coagulopathy. To this end, multiple surgeons or surgical teams should be utilized whenever feasible. Patients then require ongoing resuscitation followed by early and frequent return to the operating suite throughout the evacuation chain. Utilizing this approach, a high survival rate with reasonable functional outcomes is achievable despite the extreme severity of the DCBI pattern.

Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models.

BACKGROUND: Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. METHODS: Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. RESULTS: With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. CONCLUSION: The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

Amputation: Evaluation and Treatment.

Combat extremity injury and amputation is a life threatening injury. Initial surgical care should focus on hemostasis followed by irrigation and debridement of contaminated and nonviable tissue. Preservation of limb length begins at the initial surgical procedure, to include retention of atypical soft tissue flaps for later reconstruction and treatment of proximal fractures. Serial irrigation and debridements are required throughout the MEDEVAC system as the evolving zone of injury becomes more mature, followed by the appropriate timing of closure outside the combat theater.

Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds.

Acute compartment syndrome (CS) is a frequent and potentially devastating complication of blunt and penetrating extremity injuries. Extremity war injuries are particularly susceptible to CS due to associated vascular injuries; high Injury Severity Score; extensive bone and soft tissue injury; and frequent transportation that may limit close monitoring of the injured extremity. Treatment consists of prompt fasciotomy of all compartments in the involved segment, over their full length. Delayed or incomplete fasciotomy is associated with worse outcomes, including muscle necrosis, infection, and amputation. Enhanced pre-deployment training of surgeons decreases the need for revision fasciotomy at higher echelons of care and should be continued in future conflicts. We recommend the liberal use of prophylactic fasciotomy prior to aeromedical evacuation and after limb reperfusion. For leg fasciotomy, we recommend a two-incision approach as it is more reproducible and allows easy vascular exposure when necessary.

Extra-articular malunions of the scapula: a comparison of functional outcome before and after reconstruction.

OBJECTIVE: To assess surgical and functional results after corrective reconstruction of malunited, scapula neck or body fractures in patients who presented with chronic pain, limited range of motion, weakness, and gross deformity of the shoulder. DESIGN: Case series. SETTING: Level I teaching trauma center. PATIENTS: Between 2000 and 2008, five patients (mean age, 44 years) underwent operative reconstruction of a malunited, scapula neck and/or body fracture. Mean time from injury to surgery was 15 months (range, 8-41 months). All patients presented with debilitating pain and weakness and were unable to return to work. When measured on three-dimensional computed tomographic scan, mean preoperative fracture deformity included 3.0 cm (range, 1.7-4.2 cm) of medial/lateral displacement, 25° (range, 10°-40°) of angular deformity, and a 25° (range, 19°-29°) glenopolar angle. INTERVENTION: Surgical osteotomy and reorientation of scapula neck and/or body, with fixation using 2.7- or 3.5-mm implants and autogenous graft, through a posterior Judet approach. MAIN OUTCOMES MEASURES: Pre- and postoperative functional measures of range of motion and strength testing and patient-based outcome scores (Disabilities of the Arm, Shoulder and Hand and Short Form-36). RESULTS: Mean follow-up was 39 months (range, 18-101 months). All patients united radiographically, were pain-free with regard to the shoulder, and expressed satisfaction with their result. Four of five patients returned to their original occupation and activities. Mean Disabilities of the Arm, Shoulder and Hand score improved from 39 (range, 27-58) preoperatively to 10 (range, 0-35) postoperatively. There were no complications. CONCLUSIONS: Malunion after nonoperative treatment of a displaced scapula fracture may be associated with poor functional and cosmetic outcomes. Operative reconstruction can yield good surgical and functional results.