Particulated Juvenile Articular Cartilage Allograft for Treatment of Chondral Defects of the Knee: Short-Term Survivorship with Functional Outcomes.

While basic science research confirms the robust biological profile of juvenile chondrocytes, the clinical outcomes after particulated juvenile cartilage allograft transplantation are not well established. A retrospective analysis of active duty servicemembers undergoing surgical treatment with particulated juvenile articular cartilage allograft transplantation for chondral defects of the knee from two military treatment facilities was completed. Demographic variables, operative details, activity limitations, and medical discharges were obtained. A total of 29 patients with 36 treated chondral defects were isolated at an average follow-up of 16.2 months. The cohort was comprised of male service members in the Army with mean age of 33.1 years. Location of chondral lesion included the patellofemoral articulation (patella 39%, trochlea 31%, bipolar lesions 8%) and condyles (31%). Offloading or realignment osteotomy procedures were performed in 7 patients (23%). Of all patients, 14 servicemembers (48%) underwent knee-related medical discharge, and one patient underwent conversion to total knee arthroplasty. In this small patient cohort, particulated juvenile cartilage allograft transplantation for chondral defects of the knee did not reliably restore military servicemembers to full military function. At least one in two patients had persisting knee pain after chondral restoration procedure. (Journal of Surgical Orthopaedic Advances 30(1):010-013, 2021).

Outcomes after bankart repair in a military population: predictors for surgical revision and long-term disability.

PURPOSE: To quantify the rate of surgical failure after anterior shoulder stabilization procedures, as well as to identify demographic and surgical risk factors associated with poor outcomes. METHODS: All Army patients undergoing arthroscopic or open Bankart repair for shoulder instability were isolated from the Military Health System Management Analysis and Reporting Tool between 2003 and 2010. Demographic variables (age, gender) and surgical variables (treatment facility volume, admission status, surgical technique) were extracted. Rates of surgical failure, defined as subsequent revision surgery or medical discharge with persistent shoulder complaints, were recorded from the electronic medical record and US Army Physical Disability Agency database. Risk factor analysis was performed with univariate t tests, χ(2) tests, and a multivariable logistic regression model with failure as the outcome. RESULTS: A total of 3,854 patients underwent Bankart repair during the study period, with most procedures having been performed arthroscopically (n = 3,230, 84%) and on an outpatient basis (n = 3,255, 84%). Patients were predominately men (n = 3,531, 92%), and the mean age was 28.0 years (SD, 7.5 years). A total of 193 patients (5.0%) underwent revision stabilization whereas 339 patients (8.8%) were medically discharged with complaints of shoulder instability, for a total combined failure rate of 13.8% (n = 532). Univariate analyses showed no significant effect for gender; however, younger age, higher facility volume, open repair, and inpatient status were significant factors associated with subsequent surgical failure. Multivariable analyses confirmed that young age (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.91 to 0.96; P < .001), open repair (OR, 0.52; 95% CI, 0.36 to 0.75; P = .001), and inpatient status (OR, 0.58; 95% CI, 0.40 to 0.84; P = .004) were independently associated with failure by revision surgery. CONCLUSIONS: Young age remains a significant risk factor for surgical failure after Bankart repair. Patients who underwent arthroscopic Bankart repair had a significantly lower surgical failure rate (4.5%) than patients who underwent open anterior stabilization (7.7%). Despite advances in surgical technique, 1 in 20 military service members required revision surgery after failed primary stabilization in this study. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Achillon mini-open Achilles tendon repair: early outcomes and return to duty results in U.S. military service members.

The purpose of this article is to report short-term outcomes and return to duty rates in a cohort of active duty U.S. military personnel who underwent repair of acute Achilles tendon ruptures using the Achillon mini-open technique. Between October 2009 and March 2012, 15 consecutive patients underwent mini-open repair of acute Achilles tendon ruptures using the Achillon device by a single surgeon. Minor and major complications were recorded, and American Orthopaedic Foot and Ankle Society (AOFAS) and pain visual analog scores were recorded at regular follow-up intervals. At mean latest follow-up of 16.7 months postoperatively, all 15 patients had returned to full active duty status without major complications. Specifically, no patient experienced major wound complication, infection, or rerupture. Mean AOFAS score in 9 of 15 patients was 94.1; mean pain visual analog score in 12 of 15 patients was 1.4. The Achillon mini-open technique can be used for treatment of acute Achilles tendon ruptures in appropriately selected high-demand patient populations with the expectation of minimal adverse outcomes.

Management and prevention of acute and chronic lateral ankle instability in athletic patient populations.

Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significant long-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and non-anatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.

The nature and incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009).

OBJECTIVES: This investigation sought to describe orthopaedic wounds sustained by service members deployed to Iraq or Afghanistan from 2005 to 2009. DESIGN: Retrospective review of prospective data. SETTING: : Joint Theater Trauma Registry (JTTR). PATIENTS: The 6092 musculoskeletal casualties contained in the JTTR. INTERVENTION: The JTTR was queried to identify all personnel sustaining musculoskeletal injuries in the period 2005-2009. Demographic information, injury mechanism, and nature of wounds were determined for all individuals. Deployment data for all service members were obtained through the Defense Manpower Data Center and the incidence of orthopaedic injuries and wounding patterns was assessed. MAIN OUTCOME MEASUREMENTS: Pairwise comparisons were made to identify statistically significant differences in incidence, and significant associations, between injury mechanism and injuries/wounding patterns. RESULTS: The JTTR contained data on 6092 musculoskeletal casualties with 17,177 wounds. Seventy-seven percent of all casualties sustained a musculoskeletal wound. The incidence of musculoskeletal combat casualties was 3.06 per 1000 deployed personnel per year, with fractures occurring in 3.41 per 1000 and soft-tissue wounds most commonly encountered (4.04 per 1000). Amputations represented 6% of all combat wounds. Most musculoskeletal wounds were caused by explosive blast (P < 0.001), as were nearly all traumatic amputations. CONCLUSIONS: This study represents the most complete description of the scope of orthopaedic war trauma. It also presents injury-specific incidences that have not previously been described for musculoskeletal combat casualties. Musculoskeletal casualties may occur in 3 of every 1000 personnel deployed per year. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Combat wounds in Iraq and Afghanistan from 2005 to 2009.

BACKGROUND: There have been no large cohort studies examining the wounding patterns and injury mechanisms in Iraq and Afghanistan from 2005 to 2009. This investigation sought to characterize the incidence and epidemiology of combat-related injuries for this period. METHODS: Using the Joint Theater Trauma Registry, a detailed description of the combat casualty care statistics, distribution of wounds, and injury mechanisms sustained by all US service members for wounds (DRG International Classification of Diseases-9th Rev. codes 800-960) during the Iraq and Afghanistan Wars from 2005 to 2009 was performed. RESULTS: Among the 1,992,232 military service members who were deployed, there were 29,624 distinct combat wounds in 7,877 combat casualties. The mean age of the combat casualty cohort was 26.0 years old. The combat casualties were predominantly male (98·8%), Army (77·5%), and junior enlisted (59·0%). The distribution of combat wounds was as follows: head/neck, 28·1%; thorax, 9·9%; abdomen, 10·1%; and extremities, 51·9%. Explosive injury mechanisms accounted for 74·4% of all combat casualties, which was significantly higher than those caused by gunshot wounds (19·9%) (p < 0.0001). From 2005 to 2007, explosive mechanisms of injury were significantly more common in Iraq than in Afghanistan (p < 0.001). The percentage of explosive mechanisms increased significantly in Afghanistan between the years 2007 (59·5%) and 2008 (73·6%) (p < 0.0003). CONCLUSION: The wounding patterns observed in Iraq and Afghanistan from 2005 to 2009 differ from previous conflicts. Explosive mechanisms accounted for 74·4% of combat casualties, which is a higher percentage than in previous US conflicts. A progressive increase in the use of explosive mechanisms in Afghanistan, eventually equaling that in Iraq, was observed during the study period.

Combat-related gunshot wounds in the United States military: 2000-2009 (cohort study).

INTRODUCTION: The armed forces of the United States are engaged in the longest conflict in their history. No prior works have described the incidence or epidemiology of gunshot wounds in the U.S. military. METHODS: All combat-related gunshot wounds sustained by uniformed servicemembers in the years 2000-2009 were identified using the Defense Medical Epidemiology Database. Demographic information for all individuals identified as having sustained gunshot injuries was obtained and like data was captured for the entire military population serving in the same time-period. Raw unadjusted incidence rates were calculated for gunshot wounds within the entire demographic, as well as for the subcategories of sex, military rank, branch of service, and age. Adjusted incidence rate ratios were also calculated via multivariate Poisson regression analysis, using subcategories with the lowest unadjusted incidence rates as referents. RESULTS: We identified 4693 gunshot wounds within a population of 13,813,333 person-years for an overall incidence of 0.34 per 1000 person-years. Marine Corps service demonstrated the highest unadjusted incidence rate at 0.68 per 1000 person-years. Male sex, Junior Enlisted rank, Army and Marine Corps service, and ages 20-29 demonstrated significant adjusted incidence rate ratios and maintained unadjusted incidence rates above the population mean. CONCLUSIONS: Male sex, Junior Enlisted rank, Army and Marine Corps service, and ages 20-29 were identified as significant independent risk factors for war-related gunshot injuries. This investigation is the first to report on the incidence and epidemiology of gunshot wounds and includes the largest cohort of individuals to sustain such injuries in the literature.