Return to Duty Following a Tibial Tubercle Osteotomy.

Anterior knee pain is a common complaint among military members, with a negative impact on operational readiness. A tibial tubercle osteotomy is one treatment option for select etiologies of anterior knee pain and has been reported to result in high rates of return to activity. A retrospective review of active duty service members undergoing a tibial tubercle osteotomy at a single army medical center was performed. Thirteen active duty service members were identified as undergoing a tibial tubercle osteotomy. Nine patients remained on active duty at 1 year following surgery. After 24 months, only four service members remained on active duty, while seven were medically retired. Seventy-five percent of patients who underwent concomitant cartilaginous procedure underwent a medical discharge. A small subset of active duty military personnel who underwent a tibial tubercle osteotomy was able to remain on active duty, but concomitant cartilaginous procedures did not appear to be compatible with retention on active duty because of the high physical demands placed on soldiers. (Journal of Surgical Orthopaedic Advances 26(4):262-265, 2017).

Outcomes of biceps tenodesis in an active duty population.

Pathology affecting the long head of the biceps tendon and its insertion is a frequent cause of shoulder pain in the active duty military population. The purpose of this investigation was to evaluate functional outcomes of subpectoral biceps tenodesis in an active duty population. A retrospective case series of 22 service members who underwent biceps tenodesis was performed and Shoulder Pain and Disability Indexes (SPADI) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained preoperatively and at 6 months. Additionally, a review of each subject's physical profile was performed 6 months after surgery to determine continued physical limitations and one's ability to deploy. There was a statistically significant improvement in SPADI and DASH scores comparing preoperative versus postoperative outcomes. Although five subjects (22%) continued to have a restriction to performing push-ups on the Army Physical Fitness Test, all were deemed deployable from a physical standpoint. The results of this review suggest that active duty personnel undergoing biceps tenodesis have significant functional improvement at 6 months. Additionally, very few have long-term physical limitations or deployment restrictions.

FUNCTIONAL OUTCOMES OF HIP ARTHROSCOPY IN AN ACTIVE DUTY MILITARY POPULATION UTILIZING A CRITERION-BASED EARLY WEIGHT BEARING PROGRESSION.

INTRODUCTION: Hip arthroscopy allows surgeons to address intra-articular pathology of the hip while avoiding more invasive open surgical dislocation. However the post-operative rehabilitation protocols have varied greatly in the literature, with many having prolonged periods of limited motion and weight bearing. PURPOSE: The purpose of this study was to describe a criterion-based early weight bearing protocol following hip arthroscopy and investigate functional outcomes in the subjects who were active duty military. METHODS: Active duty personnel undergoing hip arthroscopy for symptomatic femoroacetabular impingement were prospectively assessed in a controlled environment for the ability to incorporate early postoperative weight-bearing with the following criteria: no increased pain complaint with weight bearing and normalized gait pattern. Modified Harris Hip (HHS) and Hip Outcome score (HOS) were performed preoperatively and at six months post-op. Participants were progressed with a standard hip arthroscopy protocol. Hip flexion was limited to not exceed 90 degrees for the first three weeks post-op, with progression back to running beginning at three months. Final discharge was dependent upon the ability to run two miles at military specified pace and do a single leg broad jump within six inches of the contralateral leg without an increase in pain. RESULTS: Eleven participants met inclusion criteria over the study period. Crutch use was discontinued at an average of five days following surgery based on established weight bearing criteria. Only one participant required continued crutch use at 15 days. Participants' functional outcome was improved postoperatively, as demonstrated by significant increases in HOS and HHS. At the six month follow up, eight of 11 participants were able to take and complete a full Army Physical Fitness Test. CONCLUSIONS: Following completion of the early weight bearing rehabilitation protocol, 81% of participants were able to progress to full weight bearing by four days post-operative, with normalized pain-free gait patterns. Active duty personnel utilizing an early weight bearing protocol following hip arthroscopy demonstrated significant functional improvement at six months. LEVEL OF EVIDENCE: Level 4, Case-series.

Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement.

BACKGROUND: Arthroscopic debridement is the standard of care for the treatment of acetabular labral tears. The Short Form-36 has not been used to measure hip arthroscopy outcomes, and the impact of disability status on hip arthroscopy outcomes has not been reported. HYPOTHESIS: Short Form-36 subscale scores will demonstrate good correlation with the modified Harris hip score, but patients undergoing disability evaluation will have significantly worse outcome scores. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The records of active-duty soldiers who underwent hip arthroscopy at the authors' institution were retrospectively reviewed. Forty consecutive patients who underwent hip arthroscopy for the primary indication of labral tear formed the basis of the study group. Patients completed the modified Harris hip score, the Short Form-36 general health survey, and a subjective overall satisfaction questionnaire. RESULTS: Thirty-three patients, with a mean age of 34.6 years, were available for follow-up at a mean of 25.7 months postoperatively. Fourteen (43%) patients were undergoing medical evaluation boards (military equivalent of workers' compensation or disability claim). Pearson correlation coefficients for comparing the Short Form-36 Bodily Pain, Physical Function, and Physical Component subscale scores to the modified Harris hip score were 0.73, 0.71, and 0.85, respectively (P < .001). The mean modified Harris hip score was significantly lower in patients on disability status than in those who were not (92.4 vs 61.1; P < .0001). The Short Form-36 subscale scores were significantly lower in disability patients (P < .02). Patient-reported satisfaction rates (70% overall) were 50% for those undergoing disability evaluations and 84% for those who were not (P < .04). There was no significant difference in outcomes based on patient age, surgically proven chondromalacia, or gender for military evaluation board status. CONCLUSION: The Short Form-36 demonstrated good correlation with the modified Harris hip score for measuring outcomes after arthroscopic partial limbectomy. Arthroscopic debridement yielded a high percentage of good results when patients undergoing disability evaluations were excluded. Disability status may be a negative predictor of success after hip arthroscopy.

Idiopathic chondrolysis of the ankle.

A 21-year-old West Point cadet presented to our institution with a history of chronic left lateral ankle instability. The initial injury occurred 5 years earlier. Physical examination results and stress radiographs were consistent with lateral instability. The patient underwent an ankle arthroscopy and lateral ankle ligament reconstruction. Arthroscopic findings included moderate synovitis, grade II anterolateral chondrosis, and an anterior talar osteophyte. The patient had an uneventful postoperative course and returned to activity. Eleven months after surgery he presented with increased left ankle pain. On physical examination he had a stable ankle, but radiographs revealed marked loss of ankle joint space. Significant diffuse fraying and thinning of the articular cartilage noted on repeat arthroscopy were consistent with chondrolysis.

Backfill for iliac-crest donor sites: a prospective, randomized study of coralline hydroxyapatite.

We report on a prospective randomized study of coralline hydroxyapatite (CH) used as backfill for iliac-crest donor sites. Autogenous iliac-crest bone graft is routinely harvested for spinal fusion. Donor-site morbidity is underappreciated; the presumption is that donor sites regenerate. In this study, we assessed the biological viability of the backfill CH (Pro OsteonTM Implant 500 Hydroxyapatite Bone Void Filler; Interpore, Irvine, Calif) and compared donor-site morbidity after harvest. Twelve patients (11 men, 1 woman) were enrolled: 5 in the backfill group and 7 in the no-backfill group. As part of routine evaluations done preoperatively and 6 weeks, 3 months, 6 months, and 1 year postoperatively, plain radiographs and computed tomography (CT) scans were used to assess bone ingrowth, and technetium bone scans were used to assess biological activity. Postoperative pain analysis was also done. Ten patients (9 men, 1 woman) completed the study. Of the 4 completers in the backfill group, 3 (75%) showed bony ingrowth on plain radiographs and CT scans at 1 year; the fourth patient showed bony ingrowth only on plain radiographs. All 4 patients showed biological activity on bone scans and reported mild pain to no pain. Of the 6 completers in the no-backfill group, 1 (17%) showed bony ingrowth on plain radiographs and CT scans. No patient showed biological activity on bone scans at 1 year. CH aids in iliac-crest healing after bone-graft harvesting by acting as a biological osteoconductive matrix. Postoperative pain at the bone-graft site is potentially reduced. More studies of larger numbers of patients are needed to assess the true long-term benefits of this material in a clinical setting.

Long-term follow-up of female patients with idiopathic scoliosis treated with the Wilmington orthosis.

BACKGROUND: A spinal orthosis is commonly utilized in the nonoperative treatment of idiopathic scoliosis. The purpose of this study was to evaluate the long-term radiographic and functional outcomes of female patients with idiopathic scoliosis who had completed a program of treatment with the Wilmington thoracic-lumbar spinal orthosis. METHODS: We retrospectively reviewed the clinical records and radiographs of all female patients who had successfully completed a course of treatment with the orthosis between 1973 and 1983. Ninety-one patients met the criteria for inclusion, and fifty-five women returned for a follow-up evaluation. Their mean age was thirty-one years at the time of follow-up, which was carried out at a mean of 14.6 years after the completion of treatment. The patients were evaluated clinically and radiographically, and they each completed a comprehensive questionnaire assessing their ability to perform twenty-six activities of daily living, their overall physical appearance, the cosmetic appearance of the back, their self-image, and the severity of any back pain. The questionnaire was also administered to a control group of fifty-five women without scoliosis matched for age, number of children, and occupation. RESULTS: Seven patients (13%) demonstrated >or=5 degrees of progression of the curve, compared with the curve at the start of treatment, after discontinuing use of the orthosis. No curve progressed >17 degrees compared with the deformity at the time of the initial treatment. There was no significant overall difference between the orthotic treatment group and the control group in terms of back pain, physical activities, functional activities (with the exception of shopping) or self-care activities. As a group, the patients reported significantly greater difficulty with selected positional activities (p = 0.007). Fifty-one (93%) of the fifty-five treated women reported no subjective deterioration in their physical appearance, the cosmetic appearance of the back, or their self-image in the period since they discontinued using the brace. CONCLUSIONS: The majority of patients who successfully complete treatment with a Wilmington thoracic-lumbar spinal orthosis for idiopathic scoliosis with an initial magnitude of between 20 degrees and 45 degrees can anticipate that the curve will remain stable into middle adulthood. Any apparent correction of the curve that occurs during treatment can be expected to be lost over time, resulting in a deformity that is equal or nearly equal in magnitude to that measured at the initiation of the orthotic management. Because some patients did demonstrate some progression of the curve by the third or fourth decade of life, it is reasonable to recommend a spinal radiograph during that time to monitor the status of the curve.

Lower extremity stress fractures in the military.

Stress fractures of the lower extremities are common among the military population and, more specifically, military recruits who partake in basic training. Both intrinsic and extrinsic factors play a role in the development of these injuries, and it is important to identify those individuals at risk early in their military careers. Some of these factors are modifiable, so they may become preventable injuries. It is important to reiterate that one stress fracture places the soldier at risk for future stress fractures; but the first injury should not be reason enough for separation from the military, as literature would support no long-term deficits from properly treated stress fractures. Early in the process, radiographic analysis is typically normal; continued pain may warrant advanced imaging, such as scintigraphy or MRI. Most stress fractures that are caught early are amendable to nonoperative management consisting of a period of immobilization and NWB followed by progressive rehabilitation to preinjury levels. Complete or displaced fractures may require operative intervention as do tension-sided FNSF. Improving dietary and preaccession physical fitness levels may play a role in reducing the incidence of stress fractures in the active-duty military population. It is important to keep in mind when evaluating soldiers and athletes who present with activity-related pain that stress fractures are not uncommon and should be given significant consideration.

Snapping knee caused by symptomatic fabella in a native knee.

We report a case of a 31-year-old man with a 5-year history of snapping knee syndrome secondary to a single, large symptomatic fabella of the knee. On physical examination, the patient was able to reproduce an audible and palpable snapping with active range of motion. His condition was refractory to physical therapy. He had undergone a prior iliotibial band release at an outside facility. After excision of the fabella, measuring 15 × 8 × 9 mm, the patient's snapping and pain with activity were resolved.

ACL reconstruction in a deployed environment in support of operation enduring freedom: a surgical technique.

Military orthopaedic surgeons in deployed environments along with orthopaedic surgeons working in more austere environments often find themselves without surgical equipment that they are normally accustomed to having in the operative suite. Today's U.S. Army Combat Support Hospital is appropriately focused on being prepared for modern battlefield trauma but lacks the resources for advanced sports medicine surgery to include arthroscopic equipment and implants. In this report, we describe an autograft anterior cruciate ligament reconstruction procedure using a combined mini-open extra-articular/intra-articular technique. This method could serve as a model for orthopaedic surgeons operating in more austere environments without modern sports medicine equipment and when working with the local national population who do not have access to modern health care facilities.

Gender and age differences in growth factor concentrations from platelet-rich plasma in adults.

The use of platelet-rich plasma (PRP) to facilitate healing of orthopedic-related injuries has gained popularity; however, the clinical benefits are not consistent. Differences may result from variations in growth factor (GF) levels in normal populations. The purpose of this study was to determine if GF levels present in activated PRP preparations differed by gender and age (≤ 25 versus >25 years) in a healthy population (N = 102). All GFs analyzed (epidermal growth factor [EGF], hepatocyte growth factor [HGF], insulin growth factor-1 [IGF-1], platelet-derived growth factor-AB [PDGF-AB], platelet-derived growth factor-BB [PDGF-BB], transforming growth factor beta-1 [TGFß-1], and vascular endothelial growth factor) had higher levels for females and for those ≤ 25 years old. Of the GFs tested, four of seven were significantly higher (p < 0.05) for females (EGF, HGF, IGF-1, PDGF-BB), the most significant being IGF-1 (female, 85.0; male, 69.3 ng/mL; p < 0.01). Five of seven GFs achieved significance (p < 0.05) for people ≤ 25 years old (EGF, IGF-1, PDGP-AB, PDGF-BB, and TGFß-1), with IGF and PDGF-AB achieving p < 0.001 (≤ 25 years, 85.1; >25 years, 56.8, and ≤ 25 years, 7.66; >25 years, 5.77 ng/mL, respectively). Finally, for both genders, most of the GFs were positively correlated with all GFs. This study demonstrated that both age and gender account for variations in specific GFs present in PRP, and this may partially explain some of the inconsistent results of PRP clinical trials.

Variance of matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase (TIMP) concentrations in activated, concentrated platelets from healthy male donors.

BACKGROUND: The use of autologous blood concentrates, such as activated, concentrated platelets, in orthopaedic clinical applications has had mixed results. Research on this topic has focused on growth factors and cytokines, with little directed towards matrix metalloproteinases (MMPs) which are involved in post-wound tissue remodeling. METHODS: In this study, the authors measured the levels of MMP-2, MMP-9 and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), in activated platelets derived from blood of healthy, male volunteers (n = 92), 19 to 60 years old. The levels of the natural inhibitors of these proteases, tissue inhibitor of metalloproteinase 1 (TIMP-1), TIMP-2 and TIMP-4 were also assessed. RESULTS: Notably, there was no significant change in concentration with age in four of six targets tested. However, TIMP-2 and TIMP-4 demonstrated a statistically significant increase in concentration for subjects older than 30 years of age compared to those 30 years and younger (P = 0.04 and P = 0.04, respectively). CONCLUSION: TIMP-2 and TIMP-4 are global inhibitors of MMPs, including MMP-2 (Gelatinase A). MMP-2 targets native collagens, gelatin and elastin to remodel the extracellular matrix during wound healing. A decreased availability of pharmacologically active MMP-2 may diminish the effectiveness of the use of activated, concentrated platelets from older patients, and may also contribute to longer healing times in this population.

Open, combat-related loss, or disruption of the knee extensor mechanism: treatment strategies, classification, and outcomes.

OBJECTIVE: To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. DESIGN: Retrospective review. SETTING: Tertiary (Level/Role V) Military Treatment Facility. PATIENTS: Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. INTERVENTION: Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. MAIN OUTCOME MEASURES: Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. RESULTS: The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. CONCLUSIONS: High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Intravenous angiocatheters as a novel alternative to Semmes-Weinstein monofilament evaluation in testing protective sensation.

Semmes-Weinstein monofilament (SWM) evaluation for protective sensation in diabetic feet is a widely used tool to guide patient care. Little evidence is available for alternative testing modalities for use when monofilament is not available or is deformed. Multiple varieties of intravenous angiocatheter tubing were subjected to biomechanical testing on a digital scale to assess the force generated once bending was observed by five independently tested raters. A 5.07 SWM (10 g) was tested in similar manner to establish a baseline and validate testing methodology. The 24 gauge × 0.75 in angiocatheter measured the closest to the 5.07 SWM (10 g) at an average force of 22 ± 0.91 g compared with 10.2 ± 0.13 g. Large-gauge angiocatheters measured greater forces. High intra-rater and inter-rater reliability was observed with all values greater than 0.98 (p < 0.001). A 24 gauge × 0.75 in angiocatheter tubing can be used as an alternative to the standard 5.07 SWM (10 g) for testing protective sensation in diabetic feet. Reviewing previously published receiver operating characteristics, this modality would yield estimated sensitivity and specificity values greater than 0.8 and 0.7, respectively, for detecting insensate feet tested at the bilateral metatarsal heads.

Use of CT-arthrography and ultrasound in ACL surgery during Operation Enduring Freedom in Afghanistan: a case report and practice recommendations.

The availability of magnetic resonance imaging is severely limited in a deployed environment. However, advanced imaging for diagnosis and treatment of musculoskeletal soft-tissue injuries in theater does exist. Computed tomography (CT), arthrography, and ultrasound are readily available at Role 2 and 3 Medical Treatment Facilities in Afghanistan in support of Operation Enduring Freedom. In this report, we describe a case using CT arthrogram and ultrasound to assist with the diagnosis, treatment, and follow-up of an anterior cruciate ligament reconstruction surgery performed at a Role 2E hospital at Camp Arena, Herat, Afghanistan on a coalition soldier. All physicians who treat musculoskeletal injuries in theater should be familiar with the musculoskeletal applications of ultrasound and CT arthrography. Finally, treatment of the local population and coalition soldiers who do not have access to magnetic resonance imaging will be improved with the knowledge and use of existing advanced imaging in a deployed and austere setting.

A criterion based sling weaning progression (sweap) and outcomes following shoulder arthroscopic surgery in an active duty military population.

INTRODUCTION: Little objective evidence is available to guide rehabilitation protocols in regard to the sling weaning process following arthroscopy surgery of the shoulder. The purpose of this study was to establish an objective, criterion based protocol for accelerated sling weaning following shoulder arthroscopy. METHODS: 82 active duty service members (ADSM) underwent elective shoulder arthroscopic surgery by three orthopaedic staff surgeons. One physical therapist progressed patients through the criterion based sling weaning progression (SWEAP) protocol for each surgery and documented pain levels, sleep habits, and decrease in sling use. Preoperative and six month postoperative Quick Disability of the Arm, Shoulder, and Hand (qDASH) and Shoulder Pain and Disability Index (SPADI) scores were obtained. The ability to perform an Army Physical Fitness Test (APFT) was recorded at six months postoperative. RESULTS: Patients completed sling weaning at an overall mean of 16.6 ± 5.0 days with continued use in unprotected military settings only beyond this timeframe. As patients steadily progressed out of the sling for 1 hour, 2-3 hours, and half-day periods, average pain scores decreased during these time periods at 5.0±1.2, 3.7±1.2, and 2.1±1.3 (0-10 pain scale), respectively. Patients obtained 6-7 hours of sleep or normal sleep habits at an average of 10.9±4.4 days postoperative. Overall, preoperative qDASH and SPADI scores improved from 39.8±13.0 to 2.4±2.0 and 46.4±16.1 to 3.3±3.2, respectively, at 6 months follow up. All 82 patients were able to return to deployable status. 30 (36.6%) patients required formal restrictions for the push-up portion of the APFT at six months postoperative. 7 of these 30 patients required running restrictions. CONCLUSIONS: Early improvement in quality of life indicators can be obtained in the initial postoperative period with a progressive, criterion based SWEAP protocol. Patients demonstrated favorable outcomes with return to occupational and physical fitness activities. This study will guide orthopedic surgeons and physical therapists to enhance the sling weaning process during rehabilitation protocols and improve preoperative counseling sessions for accurate postoperative expectations. STUDY DESIGN: Retrospective Case Series; Level of evidence 4.

Giant cell tumor: a case report of recurrence during pregnancy.

STUDY DESIGN: Descriptive. OBJECTIVE: To report a case of a recurrent giant cell tumor (GCT) of the lumbar spine during pregnancy. SUMMARY OF BACKGROUND DATA: GCT is a locally aggressive tumor that primarily occurs in young female adults. These tumors rarely present in the spine, recur locally, and may be present during pregnancy because of growth promoting receptors. METHODS: A 31-year-old pregnant woman presented to us from Europe at 24 weeks' gestation (G1P1) with severe back pain and an enlarging mass. A large, firm, nontender mass was palpable in the right upper quadrant. Radiographs of the lumbar spine were obtained and revealed a 10-cm x 8 cm x 15 cm expansive bony mass at L2 with vertebral body collapse and junctional kyphosis. Following delivery of a healthy 6 lb. 8 oz. baby, MRI, CT, and full-length standing radiographs were obtained. A needle-guided biopsy showed amorphous bone with numerous giant cells consistent with a GCT. At 6 weeks postpartum, the tumor was resected. RESULTS: At 1-year follow-up, there is no evidence of local reoccurrence and the patient is without constitutional symptoms. CONCLUSION: This is an unusual presentation of an expanding intra-abdominal mass originating from the lumbar spine during pregnancy. It most likely represents rapid growth of a previous unrecognized recurrence of a GCT. Close observation and follow-up CT scanning are imperative to identify and treat GCTs of the spine before rapid growth occurs.

Bilateral lipoma arborescens of the bicipitoradial bursa.

A 37-year-old military mechanic presented to our institution with a chronic history of a slowly enlarging left elbow antecubital fossa mass. There was no history of other chronic illness or trauma. Magnetic resonance imaging (MRI) and excisional biopsy revealed fatty villi and synovial inflammation within the left bicipitoradial bursa, consistent with lipoma arborescens. Four years later the patient presented with a 6-month history of swelling at the antecubital fossa of the opposite elbow. Diagnostic computed tomography and MRI examinations were performed. The surgical and pathologic findings confirmed the imaging diagnosis of lipoma arborescens at the right bicipitoradial bursa.