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.

Teaching Professional Development to Orthopaedic Residents.

BACKGROUND: The traditional focus of residency training programs has been on the development of clinical and surgical skills. The expectation has been that nonclinical skills, including professional development, will be learned in an informal manner rather than through formal teaching. METHODS: After recognizing the absence of formal teaching on professional development in the residency curriculum, we developed a symposium to specifically address this omission. Topics included applying for fellowships, military promotions, overseas assignments, moonlighting, board certification, time management, lifelong orthopaedic learning, and finding a job after the military. Residents were surveyed before and after the symposium to determine the overall usefulness and value of the individual topics. RESULTS: All participating residents reported that they would recommend the symposium to other residents. The course received a mean overall rating of 4.64 (range, 4-5) on a on a scale from 1 (poor) to 5 points (excellent). High ratings were received for course usefulness, content, and relevance to future practice. CONCLUSIONS: A formal professional development program to address topics that are relevant to practice and learning should be integrated into an orthopaedic surgery residency curriculum.

Coaptation splinting for humeral shaft fractures in adults and children: a modified method.

Coaptation splinting is an accepted form of treatment for humeral shaft fractures in both children and adults. However, application may be difficult when working alone or with an uncooperative patient. We describe a modified method, involving supplies easily found in most emergency departments and cast rooms, that mitigates these problems.

Intra-articular synovial sarcoma treated with a transfemoral amputation: a case report and review of the literature.

A case of monophasic intra-articular synovial sarcoma in the right knee of a 39-year-old active duty serviceman treated with a transfemoral amputation is presented. The patient was evaluated for right knee pain and fullness. After further workup, the patient underwent computed tomography guided biopsy, with the tissue specimen consistent with intra-articular synovial sarcoma. The patient elected for a transfemoral amputation rather than limb or joint-sparing surgery. The gross specimen measured 3.5 × 3.0 × 1.7 cm in the posteromedial knee. No metastatic lesions were seen on positron emission tomography-computed tomography. Chemotherapy and radiation therapy have not been utilized. The transfemoral amputation adds to the uniqueness of this report and is discussed with a review of the multimodality treatment toward intra-articular synovial sarcoma in prior published literature.

Recurrent PET FDG Uptake after Sequential Chemotherapy and Radiation Therapy for DLBCL of the Tibia: A Case Report and Review of the Literature.

The aim of this paper is to report on the challenges associated with identifying disease recurrence following combined modality therapy (CMT) for primary lymphoma of the tibia in which an intramedullary nail has been placed. A patient with primary bone lymphoma (PBL) was treated with CMT (chemotherapy and radiation therapy). After a complete response, he has been followed for eighteen months by physical exam and radiographic imaging. Despite persistent increased tracer accumulation at the original site, he has no proven recurrence. Literature review showed a small number of retrospective, single institution reviews detailing clinical experience and expected outcome in patients treated with PBL limited to one bony site of disease. PBL presents a treatment challenge, particularly when a weight-bearing long bone is diffusely involved and followup is complicated after placement of stabilizing hardware. Close coordination of the oncology team and diagnostic radiology is required to ensure optimal outcome.

Does antibiotic elution from PMMA beads deteriorate after 1-year shelf storage?

Antibiotic-impregnated polymethylmethacrylate beads are widely used as an adjunct in the treatment of orthopaedic infections. Because there is no commercially available bead in the United States, surgeons must manufacture bead sets at the time of implantation. This can be time consuming and wasteful. We hypothesized antibiotic-impregnated beads would maintain consistent elution for up to 1 year after manufacturing and storage. Tobramycin-impregnated antibiotic beads were manufactured using a bead mold. The antibiotic was either hand-mixed into the polymethylmethacrylate powder (1.2 g/40 g) or came premixed from the factory (1 g/40 g). Packages of beads were gas-sterilized and stored at room temperature. Beads were tested at 0, 1, 2, 3, 6, and 12 months. Antibiotic levels in the eluent from each day of the month were measured. We were unable to detect any difference in the amount of antibiotic elution between beads tested immediately after manufacture and beads manufactured and stored for 6 or 12 months. Beads with hand-mixed antibiotics eluted higher levels of antibiotics than the beads prepared with factory-mixed antibiotics. We conclude antibiotic beads can be made, sterilized, and used after 1 year of storage with no deleterious effect on antibiotic elution characteristics.

Distal tibial osteoarticular allografts.

Osteoarticular allografts can be used for limb reconstruction following tumor excision. Most commonly, the distal femur, proximal tibia and distal radius have been studied, while distal tibial allografts receive only sporadic mention in the literature. We evaluated the functional outcomes of distal tibial allografts used in tumor reconstruction. Following FDA guidelines and using a questionnaire, we surveyed operating surgeons on the outcomes of 29 distal tibial allografts used to reconstruct osseous defects secondary to benign and malignant tumors. Twelve patient questionnaires were returned revealing nine complications in eight patients. These included nonunions (three), fracture (two), arthrosis (two), and delayed union (two). There were no reported infections. Two patients died of their disease. The average rating using the Musculoskeletal Tumor Society (MSTS) score was 67.3%. The 10 living patients had an average rating of 72.4%. Distal tibial osteoarticular allografts offer acceptable functional results when used in tumor reconstruction. Difficulties achieving union (delayed or nonunion) between the host and the graft appears the most common complication of this technique.