At-Risk Median Motor Branch to the Thenar Musculature Crossing Under the Flexor Carpi Radialis in the Forearm: A Case Report.

CASE: A 77-year-old woman who sustained a distal radius and ulna fracture underwent open reduction internal fixation through a standard flexor carpi radialis (FCR) approach. On dissection, a proximal division of the median nerve was identified, with an aberrant motor branch crossing radial to ulnar deep to FCR and superficial to flexor pollicis longus. CONCLUSION: Although many anatomic variants of the median nerve have been described, the current case demonstrates a particularly important median motor branch variant, imposing a substantial risk of iatrogenic injury during a standard FCR approach.

Treatment of Cartilage Defects of the Knee in Military Tactical Athletes: An Overview of Management and Clinical Outcomes.

Cartilage defects of the knee are a common problem that can be caused by trauma or chronic repetitive overload and result in debilitating functional limitations. These consequences are of particular significance to military service members, who, by in large, are a group of young, active individuals with professional duties requiring full, unrestricted activity and function. The burden of knee chondral-related disease among military tactical athletes is well established, and systematic approach to the evaluation of a military member with suspected knee chondral pathology facilitates the execution of a surgical procedure that maximizes the likelihood of a return to duty. Despite advances in cartilage restoration surgery, chondral pathology of the knee remains a vexing problem and an omnipresent threat to military medical readiness and warfighter lethality.

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability.

BACKGROUND: Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well. HYPOTHESIS: The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility. RESULTS: A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ2(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ2(2) = 9.4; P = .009). CONCLUSION: The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

MRI Does Not Reliably Detect Kaplan Fiber Injury In Skeletally Immature Patients with an Acute ACL Tear.

Background: To our knowledge, there have been no previous efforts to evaluate the prevalence of Kaplan fiber (KF) injury in skeletally immature patients with an acute anterior cruciate ligament (ACL) tear on magnetic resonance imaging (MRI) nor has there been any comparison of the reliability of previously described KF diagnostic criteria in this cohort. Purpose: To define the prevalence of KF injury in the setting of acute ACL tears using MRI performed within 90 days of injury among skeletally immature patients, and to compare the reliability of MRI in detecting KF injuries using 2 previously described diagnostic criteria. Study Design: Cohort study; Level of evidence, 3. Methods: Skeletally immature patients with an acute ACL tear confirmed using MRI within 90 days of injury were assessed. Two fellowship-trained musculoskeletal radiologists independently interpreted each MRI scan twice. KF injury was first assessed using the Van Dyck scheme (grade 0, normal; grade 1, periligamentous; grade 2, partial tear; and grade 3, complete tear). MRI scans were then reviewed again using the KF injury criteria proposed by Batty. Discrepancies in KF injury schemes were adjudicated by a third musculoskeletal radiologist. Interrater agreement for both methods was determined using Cohen κ. Results: Included were 45 patients (33 male, 12 female) with a mean age of 13.2 ± 1.6 years. KF injuries were identified in 17 of 45 (37.7%) knees of using the traditional Van Dyck grading scheme (interrater agreement κ = 0.40). The Batty diagnostic criteria identified KF injury in 5 of 45 (11.1%) (interrater agreement κ = 0.45); 17 (37.8%) MRI scans required a third reviewer adjudication for the Van Dyck scheme, while 4 (8.9%) required a third reviewer using the Batty criteria. Conclusion: The Batty diagnostic criteria detected a lower KF injury prevalence than previously reported in the adult population, while the Van Dyck prevalence was similar to rates in adult populations. Both grading criteria had poor interrater reliability in diagnosing a KF injury.

Current Practice Patterns in Anterior Cruciate Ligament Reconstruction Among Fellowship-Trained Military Orthopaedic Surgeons.

PURPOSE: To evaluate current practice patterns in anterior cruciate ligament reconstruction (ACLR) surgery among fellowship-trained military surgeons. METHODS: The MOTION database is a prospectively collected dataset of intraoperative variables across the Military Health System. This database was queried using Current Procedural Terminology code 29888 for ACLR among active-duty service members between October 2016 and December 2019. The intraoperative data pertaining to ACLR involving both isolated primary ACLRs and primary ACLRs combined with meniscal or chondral injuries were extracted with patient age, sex, and rank. RESULTS: Two hundred sixty-six primary ACLRs performed by 21 fellowship-trained orthopaedic surgeons at 9 MTFs were identified. The mean age of patients undergoing ACLR was 27.2 ± 7.7 years. Bone-patellar tendon-bone autograft was the most commonly used graft source (137 of 266 [51.5%] cases.) Meniscal injuries were treated with an isolated debridement in 53 of 156 (34.0%) tears, whereas meniscal repair was performed in 86 of 156 (55.1%) tears. Concomitant chondral pathology was noted in 43 of 266 cases (16.2%) and most commonly addressed with chondroplasty (25 of 49 [51.0%] chondral lesions). CONCLUSIONS: Bone-patellar tendon-bone autograft was the most commonly used graft type in ACLR among fellowship-trained surgeons treating active-duty service members. Concomitant meniscal pathology was encountered at rates comparable with what has been previously reported, and meniscal repair was favored over meniscal debridement in more than 50% cases. LEVEL OF EVIDENCE: Level IV: Therapeutic case series.