Limited Durability of Extensor Mechanism Reconstruction Following Total Knee Arthroplasty: Mesh and Allograft Show Equivalent Outcomes at Five-Year Follow-Up.

BACKGROUND: Extensor mechanism disruption is a challenging complication following total knee arthroplasty. The purpose of this study was to compare outcomes between patients who received mesh versus allograft extensor mechanism reconstruction. METHODS: All patients who underwent extensor mechanism reconstruction at a single institution were screened. Demographic and surgical variables were recorded, including technique (ie, synthetic mesh versus allograft reconstruction). Patients were assessed for preoperative and postoperative extensor lag, revision, and duration of follow-up. Analyses, including Kaplan-Meier survivorships, were performed to compare mesh to allograft reconstruction. In total, 50 extensor mechanism reconstructions (30 mesh and 20 allograft) were conducted between January 1st, 2001, and December 31st, 2022. RESULTS: There were no differences between the cohorts with respect to revision (26.7 [8 of 30] versus 35.0% [7 of 20], P = .680) or failure defined as above knee amputation or fusion (6.7 [2 of 30] versus 5.0% [1 of 20], P = .808). There were also no differences in time to reoperation (average 27 months [range, 6.7 to 58.8] versus 29 months [range, 1.2 to 84.9], P = .910) or in postoperative extensor lag among patients who did not undergo a reoperation (13 [0 to 50] versus 11° [0 to 30], P = .921). The estimated 5-year Kaplan-Meier survival with extensor mechanism revision as the endpoint was similar between the 2 groups (52.1, 95% confidence interval [CI] = 25.4 to 73.3 versus 55.0%, 95% CI = 23.0 to 78.4%, P = .990). CONCLUSIONS: The purpose of this study was to present the findings of a large cohort of patients who required extensor mechanism reconstruction. Regardless of the reconstruction type, the 5-year outcomes of patients requiring extensor mechanism reconstruction are suboptimal.

Perioperative Dexamethasone is Associated With a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients.

BACKGROUND: Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS: Patients who have a history of VTE who underwent primary elective TJA from 2015 to 2021 were identified using a commercial health care database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS: Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < .001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < .001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < .001) and DVT (2.37 versus 3.01%, P < .001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio: 0.78, 95% confidence interval: 0.66 to 0.93, P = .006) and DVT (adjusted odds ratio: 0.84, 95% confidence interval: 0.74 to 0.95, P = .006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > .05). CONCLUSIONS: The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA. LEVEL OF EVIDENCE: Level III.

Orthopaedists Versus Radiologists: A Prospective Comparison of Radiographic Interpretation Between Orthopaedists and Radiologists at a Level I Trauma Center.

The purpose of this investigation was to evaluate the difference in response time, accuracy of radiographic interpretation, and frequency of changes in clinical management necessary after inaccurate reads when comparing orthopaedic and radiology providers. Data including provider response time, accuracy of radiographic interpretation and the frequency of changes in clinical management necessary after imaging reads was collected over a continuous two-month period at a Level I Trauma center. A total of 188 orthopedic injuries involving imaging were included. Orthopedic providers responded 203.2 minutes sooner than radiology providers. Accuracy of radiographic interpretation of the orthopaedic and radiology providers was 100% and 91%, respectively. Frequency of changes in clinical management after inaccurate interpretation of imaging by the orthopaedic and radiology provider was 0% and 7.6%, respectively. Based on our study, orthopaedic providers are significantly faster, more accurate, and make fewer mistakes affecting patient care while interpreting images of orthopaedic injuries than our radiology colleagues. (Journal of Surgical Orthopaedic Advances 30(2):093-096, 2021).

Incidence of Cubital Tunnel Syndrome in the U.S. Military Population.

PURPOSE: Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve entrapment syndrome. However, existing epidemiological evidence regarding the estimated incidence of the CuTS disease burden in specific populations is sparse, especially among the U.S. military. The purpose of this study was to describe the demographics and determine the incidence of CuTS among active duty U.S. military service members. METHODS: All first-time occurrences for CuTS among military members were identified using International Classification of Diseases, Ninth Revision, clinical modification code 354.2 for ulnar nerve lesions in the U.S. Defense Medical Epidemiology Database. A multivariable Poisson regression analysis was used to estimate the incidence rate ratio (IRR) per 1,000 person-years and 95% confidence intervals (95% CI), while controlling for sex, race, age, rank, and service. Rate-ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch. RESULTS: During the 10-year study period, the total number of incident cases of CuTS was 31,568, and a total of 13,745,456 person-years were documented. The overall unadjusted IRR of CuTS during the study period was 2.3 per 1,000 person-years (95% CI, 2.27-2.33). The 35- to 39-year age group had the highest adjusted IRR of CuTS. In addition, females, Caucasians, and junior enlisted service members showed significantly higher IRRs. CONCLUSIONS: Our study was able to provide baseline epidemiological data on IRRs and influential risk factors in CuTS. We demonstrated an incidence of CuTS that is comparable with previously reported IRRs, which have varied from 0.08 to 8.0 cases per 1,000 person-years. This study also found significantly higher risk for the development of CuTS with increased age and among U.S. Army service members. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Outcome measures after medial ulnar collateral ligament reconstructions in a military population.

BACKGROUND: Medial ulnar collateral ligament (MUCL) reconstruction outcomes are well described in competitive throwers but not in nonthrowers. This investigation elucidated epidemiologic variables, functional outcomes, and prognostic factors after MUCL reconstruction in young active patients. METHODS: United States military service members undergoing MUCL reconstruction were isolated using the Management Analysis and Reporting Tool (M2) database from 2009 to 2016. Demographics, injury characteristics, and surgical variables were extracted. Multivariate analysis was performed, discerning variables predictive of postoperative functional outcomes, complications, and reoperation. RESULTS: Sixty-six patients met inclusion criteria, and 47% participated in throwing sports. Of these, 36.4% reported a throwing mechanism of injury (MOI), 60.6% reported an acute trauma MOI, 59% reported preoperative ulnar nerve symptoms, and 39.4% experienced symptoms postoperatively. At final follow-up, average Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) scores were 10.8 ± 16.2 and 87.6 ± 17.1, respectively. A total of 86.4% reported no disability (DASH < 30), and 83.3% experienced good or excellent outcomes (MEPS >74). Age < 30 years, dominant arm injury, competitive throwing history, and throwing MOI correlated with improved DASH and MEPS scores, push-up count, postoperative pain and instability, and rates of ulnar nerve symptoms (P < .05). Psychiatric diagnosis and preoperative stiffness and instability were associated with lower outcome scores (P < .05). Ulnar nerve interventions did not correlate with presence or absence of postoperative ulnar nerve symptoms. CONCLUSIONS: MUCL reconstruction demonstrates a high good-to-excellent outcome rate and low complication and revision rates in young active individuals with intense upper extremity demands. Nonthrowing MOIs and psychiatric pathology are associated with postoperative complications and poorer outcomes.

Orthopaedic and Plastic Surgery Training Differences Manifested in the Analysis of Distal Radius Fracture Fixation.

All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedic surgeons. While there were no significant differences in baseline demographics between the patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFs fixed by orthopaedic surgeons. While there was a significant difference for extra-articular fractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53-57, 2019).

Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality.

Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009-2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137-143, 2019).

Orthopaedic Residency Training Structure: Implications on Quantity and Quality of Scholarship.

The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175-179, 2019).

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients.

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.

Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis.

BACKGROUND: Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis. METHODS: We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option. RESULTS: The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2). CONCLUSION: Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population.

HYPOTHESIS: The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. METHODS: All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. RESULTS: We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. CONCLUSION: Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%.

The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review.

BACKGROUND: Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty. METHODS: We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation. RESULTS: Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again. CONCLUSION: For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Predictors of Acute Complications Following Traumatic Upper Extremity Amputation.

Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009-2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113-118, 2018).

Comparing clinician use of three ankle fracture classifications.

PURPOSE: This study evaluated the accuracy and interrater reliability of US Army physician assistants (PAs) in identifying ankle fracture patterns using existing classification schemes. METHODS: Twenty-eight PAs reviewed criteria for stability, Danis-Weber, and Lauge-Hansen ankle fracture classification systems. Participants reviewed 45 ankle radiographs and independently rated each radiograph using these classification schemes. RESULTS: Participants were able to successfully identify ankle fracture stability in 82.1% of cases (95% CI, 77.6, 86.6) with established criteria. Using the Danis-Weber classification, accurate classification was achieved in 77.8% of cases (95% CI, 72.8, 82.7). The Lauge-Hansen classification system was least reliable, with accuracy of 54.5% (95% CI, 46, 63). CONCLUSION: Referring PAs can reliably discern unstable ankle fractures in more than 80% of cases. Lauge-Hansen classification was significantly less accurate than the Danis-Weber system or criteria for stability. Good communication between orthopedic surgeons and PAs and an emphasis on PA orthopedic education can improve patient care.

Osteochondral Allograft Transfer for Treatment of Osteochondral Lesions of the Talus: A Systematic Review.

PURPOSE: The purpose of this study is to present a systematic review of the literature regarding the use of fresh bulk osteochondral allograft transfer for treatment of large osteochondral lesions of the talus (OCLT) in an effort to characterize the functional outcomes, complications, and reoperation rates. METHODS: A search of the PubMed, CINAHL, Embase, and Cochrane Databases was performed between January 1, 1990, and March 1, 2016, and included all articles related to outcomes after fresh talar allograft transplantation for OCLT. Inclusion criteria were series (1) published in the English language, (2) using fresh talar allograft, and (3) reporting at least one outcome measure of interest including American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, reoperation rate, and rate of allograft collapse. Weighted averages of outcome data were used. RESULTS: Five studies involving 91 OCLT met the inclusion criteria. The mean age of the cohort was 39 years (range, 15 to 74), and 53% were male. Fresh talar allograft was transplanted into 71 medial, 18 lateral, and 2 central OCLT. At a mean follow-up of 45 ± 3.3 (range, 6 to 91) months, AOFAS scores improved from 48 preoperatively to 80 postoperatively. Pain VAS scores improved from 7.1 preoperatively to 2.7 postoperatively. Twenty-three of the 91 (25%) patients required at least one reoperation, for a total of 28 operations. The most common indications for reoperation were development of moderate to severe osteoarthritis (14%), pain due to hardware (9%), extensive graft collapse (3%), and delayed or nonunion of osteotomy site (1%). Ultimately 12 (13.2%) of the cases were considered failures, with 8 (8.8%) resulting in tibiotalar arthrodesis or ankle replacement. CONCLUSIONS: Fresh bulk allograft transplantation can substantially improve functional status as well as effectively prevent or delay the eventual need for ankle arthrodesis or replacement. However, patients must be carefully selected and counseled on the morbidity of the procedure as well as the high incidence of clinical failure (13%) and need for reoperation (25%) and revision surgery (8.8%). LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Radial Head Arthroplasty in the Active Duty Military Service Member With Minimum 2-Year Follow-Up.

PURPOSE: Radial head arthroplasty (RHA) is a viable treatment for complex radial head fracture. Whereas elbow stability and function is typically restored at short- to mid-term follow-up, the outcome in higher-demand populations is not well defined. We sought to characterize the functional and occupational outcomes following RHA in an active duty military population with intense upper extremity demands. METHODS: We retrospectively reviewed the records of all U.S. military service members undergoing primary RHA from 2010 and 2013 with a minimum of 2-year follow-up. Patient-based, injury-related, and surgical variables were extracted from the military-wide electronic medical record. Functional and occupational outcomes including pain, and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were recorded. The primary outcomes of interest were the rate and level of return to upper extremity activity. Secondary outcome measures included return to duty, complications, and revision surgery. RESULTS: Nineteen patients were included with average age 31 years and median 37 months' follow-up. Ten were Mason III, 6 were part of a terrible triad injury, and the remainder were fracture-dislocations. At an average follow-up of 3.7 years, 15 patients returned to active military duty, and 9 resumed their regular upper extremity military function. At the time of final follow-up, the average DASH score was 13. Seven patients returned to their usual level of sport and exercise, 6 at a reduced level, and 6 did not resume physical exercises secondary to pain or stiffness. Sixteen adverse outcomes among 14 patients included symptomatic heterotopic ossification (5 of 19) and neurological sequelae (4 of 19). Three elected to have a revision procedure at an average of 13 months for heterotopic ossification or loosening. CONCLUSIONS: Among active patients with radial head fractures treated with RHA, three-quarters will return to active duty military service, push-ups, and sport; however, half may report an adverse outcome unrelated to the prosthesis and only about half of patients will return to their preinjury level of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Predictability of Lower Extremity Peripheral Nervous Anatomy.

Lower extremity nervous anatomy is highly variable. This study sought to determine relationships of lower extremity peripheral nerves to anatomic landmarks. Sixteen well-preserved lower extremities were dissected. The distance from each nerve point of interest to relevant landmarks was measured in standardized fashion. The sciatic nerve divided on average 26.0% ± 5% of the distance from the superior aspect of the fibula to the greater trochanter proximal to the knee joint line [Pearson correlation coefficient (PCC) D 0.764]. The superficial peroneal nerve pierced the crural fascia at an average of 28.0% ± 6% of the fibular length proximal to the lateral malleolus (PCC D 0.718). The deep peroneal nerve emerged between the tibialis anterior and extensor hallucis longus on average 2.7% ± 0.4% of the fibular length proximal to the tibiotalar joint line (PCC D 0.530). While there was substantial variability in the course of lower extremity peripheral nerves, the study found strong correlation with femur and fibula length within each specimen. (Journal of Surgical Orthopaedic Advances 26(4):206-210, 2017).

Vascular Injuries in Combat-Specific Soldiers during Operation Iraqi Freedom and Operation Enduring Freedom.

BACKGROUND: This study sought to identify vascular injury patterns among combat-specific cavalry scout personnel within the Iraq and Afghanistan Wars. METHODS: The Armed Forces Medical Examiner System and Joint Theater Trauma Registry were queried for all injuries with the cavalry scout designation from 2003 to 2011, including those both wounded in action (WIA) and killed in action (KIA). A description of vascular injury, combat causality care statistics, mechanism of injury, and demographic data were recorded. RESULTS: Sixteen percent (n = 111) of the 701 cavalry scouts with a combat wound sustained a vascular injury. Among cavalry scouts sustaining vascular injuries, 69% were caused by an explosive mechanism of injury, 63% were KIA, and 29% had a major extremity amputation. Cavalry scout soldiers with a vascular injury were significantly more likely to result from explosion (P < 0.0001), be KIA (P < 0.0001), and occur in Iraq (P < 0.0001). The rate of noncompressible arterial injury was 65%. WIA cavalry scout soldiers with a compressible vascular injury with clear documentation of prehospital tourniquet utilization arrived at a Medical Treatment Facility in 67% of cases with a tourniquet in place. Of these transported with a prehospital tourniquet 83% survived. CONCLUSIONS: The high rates of KIA and extremity amputation among cavalry scout soldiers with a vascular injury denotes the lethality of these combat injuries. Uniformly equipping soldiers with battlefield tourniquets and educating them on their prehospital use might improve the survivorship of those servicemembers sustaining a compressible vascular injury.

Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature.

PURPOSE: To review published literature to characterize the at-risk demographic, operative indications, surgical techniques, functional outcomes, and reoperation and complication rates after operative management of chronic exertional compartment syndrome (CECS) of the lower leg. METHODS: We searched PubMed, Embase, Cochrane Database, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) through February 1, 2015, using the terms "chronic exertional" and/or "exercise induced compartment syndrome." The inclusion criteria were studies of Level I to IV evidence in English, published in 1970 or later, involving human subjects, reporting clinical outcomes of operative management of CECS of the lower leg, including at least 5 patients, and having follow-up of at least 80% and 6 months. RESULTS: Among the 204 original articles, 24 primary studies with 1,596 patients met the inclusion criteria. The mean age was 26.6 years (standard deviation, 8.9 years), and the majority of patients were male patients (70%). The total study population mostly comprised military service members (54%) and athletes (29%). Of the athletes, 83% were recreational; 9% were college level; and 8% were either national, international, or professional. The most commonly involved compartment was the anterior compartment (51%; 95% confidence interval [CI], 48.6% to 52.3%), followed by lateral (33%; 95% CI, 31.4% to 34.9%), deep posterior (13%), and superficial posterior (3%). The cumulative posterior involvement rate was 16% (95% CI, 15.1% to 17.8%). Mean follow-up was 48.8 months (standard deviation, 22.1 months; 95% CI, 47.1 to 50.5 months). Six percent underwent revision surgery. The overall complication rate was 13% (due to postoperative neurologic dysfunction, infection, and so on). CONCLUSIONS: Primary operative management of lower-extremity CECS was successful in approximately two-thirds of all young athletic patients, and 84% were satisfied with their surgical outcomes at short- to mid-term follow-up. Open fasciotomy remains the predominant surgical technique, although its comparative efficacy relative to newer endoscopic or other minimally invasive techniques is not currently known. These data may be used to guide the orthopaedic community on accurate preoperative counseling and benchmark patient outcomes for future quality-improvement initiatives. LEVEL OF EVIDENCE: Level IV, systematic review (studies ranging from Level I to Level IV).