Resident Perceptions of Virtual Reality Versus Dry Lab Simulation for Advanced Shoulder Arthroscopy Resident Training.

INTRODUCTION: Surgical training using simulation can fill gaps in traditional surgical residency learning. We hypothesize that arthroscopy training conducted on a virtual reality simulator will be preferred by orthopaedic surgery residents over a traditional dry lab simulation model. METHODS: 38 orthopaedic surgery residents at a single U.S. residency program were randomized to train for a shoulder arthroscopy procedure using either a virtual reality simulator or a table-top dry lab simulator. Training and learning preferences were then asked of the resident participants. RESULTS: Junior residents were likely to report training preference for the virtual reality simulator compared to senior residents [15/24 (62.5%) v. 8/14 (57.1%); P = .043]. Simulator preference was not influenced by subspecialty interest, prior arthroscopy experience, or simulator experience. Virtual reality simulation was associated with positive attitude towards arthroscopy and high chance of reporting learning gains on general arthroscopic understanding. Senior residents were 4.7 times more likely than juniors to report learning gains via staff discussion pre- and post-operatively. A majority of residents [34/38 (89.5%)] reported, however, wanting more simulation for training surgical skills. CONCLUSION: Simulation is a desired and potentially valuable adjunct to training orthopaedic residents in arthroscopy. Training needs do evolve; and junior arthroscopists may benefit more from virtual reality platforms for general skills. Senior residents preferred dry lab simulation, possibly because it allowed for handling of actual instruments and implants.

Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study.

INTRODUCTION: Quadriceps strength after arthroscopic knee procedures is frequently diminished several years postoperation. Blood flow restriction (BFR) training uses partial venous occlusion while performing submaximal exercise to induce muscle hypertrophy and strength improvements. The purpose of this study was to evaluate BFR as a postoperative therapeutic intervention after knee arthroscopy. METHODS: A randomized controlled pilot study comparing physical therapy with and without BFR after knee arthroscopy was conducted. Patients underwent 12 sessions of supervised physical therapy. Subjects followed the same postoperative protocol with the addition of 3 additional BFR exercises. Outcome measures included thigh girth, physical function measures, Knee Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR12), and strength testing. Bilateral duplex ultrasonography was used to evaluate for deep venous thrombosis preintervention and postintervention. RESULTS: Seventeen patients completed the study. Significant increases in thigh girth were observed in the BFR group at 6-cm and 16-cm proximal to the patella (P = 0.0111 and 0.0001). All physical outcome measures significantly improved in the BFR group, and the timed stair ascent improvements were greater than conventional therapy (P = 0.0281). The VR-12 and KOOS subscales significantly improved in the BFR group, and greater improvement was seen in VR-12 mental component score (P = 0.0149). The BFR group displayed approximately 2-fold greater improvements in extension and flexion strength compared with conventional therapy (74.59% vs 33.5%, P = 0.034). No adverse events were observed during the study. CONCLUSIONS: This study suggests that BFR is an effective intervention after knee arthroscopy. Further investigation is warranted to elucidate the benefits of this intervention in populations with greater initial impairment.

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.

Presentation and Surgical Management of Multiple Ligament Knee Injuries: A Multicenter Study from the Surgical Timing and Rehabilitation (STaR) Trial for MLKIs Network.

BACKGROUND: Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system. METHODS: This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively. RESULTS: A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range [IQR], 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved menisci (55.6%), nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication. CONCLUSIONS: A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma.

BACKGROUND: Although most combat-related amputations occur early for unsalvageable injuries, >15% occur late after reconstructive attempts. Predicting which patients will abandon limb salvage in favor of definitive amputation has not been explored. The purpose of this study was to identify factors contributing to late amputation for type III open tibia fractures sustained in combat. METHODS: Operative databases were reviewed to identify all combat-related type III open diaphyseal tibia fractures from March 2003 to September 2007. Patients were categorized based on their definitive treatment: group I, limb salvage; group II, early amputation (<12 weeks postinjury); group III, late amputation (≥ 12 weeks postinjury). Injury, treatment, and complication data were extracted from medical records and compared across groups. RESULTS: We identified 213 consecutive fractures, including 166 (77.9%) treated definitively with limb salvage, 36 (16.9%) with early amputation, and 11 (5.2%) with late amputation. There was no difference in fracture severity among the three groups. Before amputation, group III was more likely to use autograft and bone morphogenic protein (27.3%), compared with group I (4.8%) and group II (0%), and was more likely to undergo rotational flap coverage (45.5%), compared with group II (0%). Group III patients had the highest average number of revision surgeries and rate of deep soft tissue infection and were more likely to have osteomyelitis (54.5%) before amputation compared with group I (13.9%) and group II (16.7%). CONCLUSION: Patients definitively managed with late amputation were more likely to have soft tissue injury requiring flap coverage and have their limb salvage course complicated by infection.

Treatment of meniscal injuries in young athletes.

The young, active patient with a meniscal tear poses a significant challenge for the surgeon. Multiple factors influence the treatment of meniscal pathology and the ultimate goal of meniscal surgery should be to remove only torn and nonfunctional tissue by limited meniscectomy or to repair amenable tears. The chondroprotective significance of the meniscus has influenced the current treatment of meniscal injuries in young athletes with the emphasis on repairing meniscus tears to include complex tears and tears in the avascular zone. Partial meniscectomy and meniscal repair techniques have provided good long-term clinical success and return to activity. The decision to debride versus repair a meniscus depends on tear pattern, location, and the patient's willingness to comply with postoperative restrictions. In patients with symptomatic meniscus deficiency, meniscal allograft transplant is an option that may provide pain relief but may not allow return to sports. The purpose of this article is to provide a succinct review of the diagnostic and management principles for the young, active patient with a meniscal tear.

Meniscus repair and transplantation techniques.

Modern meniscal repair incorporates multiple techniques and adjunctive measures. The classic inside-out repair remains the gold standard and is most appropriate for a bucket-handle type tear of the medial or lateral meniscus. The all-inside technique has gained in popularity recently and has outcomes that approach those of the inside-out repair with decreased morbidity but increased cost. The choice of this technique is most appropriate for small tears requiring few sutures to repair. Outside-in repair can also be employed and is preferred for anterior horn tears. Surgeons may use a hybrid technique that incorporates all techniques in some challenging cases. Meniscal debridement is used for degenerative tears that are not amenable to repair. Meniscal transplantation is an option for symptomatic meniscal deficiency in young, active patients. This article discusses the technical considerations for meniscal debridement, repair, and transplantation.

Shoulder Arthroscopy Simulator Training Improves Surgical Procedure Performance: A Controlled Laboratory Study.

BACKGROUND: Previous simulation studies evaluated either dry lab (DL) or virtual reality (VR) simulation, correlating simulator training with the performance of arthroscopic tasks. However, these studies did not compare simulation training with specific surgical procedures. PURPOSE/HYPOTHESIS: To determine the effectiveness of a shoulder arthroscopy simulator program in improving performance during arthroscopic anterior labral repair. It was hypothesized that both DL and VR simulation methods would improve procedure performance; however, VR simulation would be more effective based on the validated Arthroscopic Surgery Skill Evaluation Tool (ASSET) Global Rating Scale. STUDY DESIGN: Controlled laboratory study. METHODS: Enrolled in the study were 38 orthopaedic residents at a single institution, postgraduate years (PGYs) 1 to 5. Each resident completed a pretest shoulder stabilization procedure on a cadaveric model and was then randomized into 1 of 2 groups: VR or DL simulation. Participants then underwent a 4-week arthroscopy simulation program and completed a posttest. Sports medicine-trained orthopaedic surgeons graded the participants on completeness of the surgical repair at the time of the procedure, and a single, blinded orthopaedic surgeon, using the ASSET Global Rating Scale, graded participants' arthroscopy skills. The procedure step and ASSET grades were compared between simulator groups and between PGYs using paired t tests. RESULTS: There was no significant difference between the groups in pretest performance in either the procedural steps or ASSET scores. Overall procedural step scores improved after combining both types of simulator training (P = .0424) but not in the individual simulation groups. The ASSET scores improved across both DL (P = .0045) and VR (P = .0003), with no significant difference between the groups. CONCLUSION: A 4-week simulation program can improve arthroscopic skills and performance during a specific surgical procedure. This study provides additional evidence regarding the benefits of simulator training in orthopaedic surgery for both novice and experienced arthroscopic surgeons. There was no statistically significant difference between the VR and DL models, which disproved the authors' hypothesis that the VR simulator would be the more effective simulation tool. CLINICAL RELEVANCE: There may be a role for simulator training in the teaching of arthroscopic skills and learning of specific surgical procedures.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

BACKGROUND: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Return to duty rate of amputee soldiers in the current conflicts in Afghanistan and Iraq.

BACKGROUND: The purpose of this study was to determine the percentage of amputee soldiers who sustained their injury during the current conflicts in Afghanistan and Iraq and have returned to duty. In addition, the authors plan to identify the factors that influence the amputee's likelihood to return to duty. METHODS: The computerized records of amputee soldiers who presented to the Physical Evaluation Board between October 1, 2001 and June 1, 2006 were reviewed. This data were crossreferenced with the Military Amputee Database. The following variables were extracted: age, gender, pay grade, amputation level, and final disposition. RESULTS: During the period reviewed, there were 395 major limb amputees that met inclusion criteria. Of those, 65 returned to active duty (16.5%). The average age of amputees returning to duty was more than 4 years older than those who separated from the service (31.4 vs. 27.2), p < 0.0001. Officers and senior enlisted personnel returned to duty at a higher rate (35.3% and 25.5%, respectively) when compared with junior enlisted personnel (7.0%), p < 0.0001. Those with multiple extremity amputations have the lowest return to duty rate at 3%, when compared with the overall return to duty rate for single extremity amputees (20%), p < 0.0001. CONCLUSION: During the 1980s, 11 of 469 amputees returned to active duty (2.3%). The number of amputees returning to duty has increased significantly, from 2.3% to 16.5%, due to advancements in combat casualty care and the establishment of centralized amputee centers.

Temporary external fixation is safe in a combat environment.

BACKGROUND: External fixation has been used extensively during recent wars as a damage control measure for fractures in coalition forces being evacuated. We hypothesize that external fixation is a safe and effective initial stabilization procedure for combat-related open fractures. METHODS: Records on 55 consecutive type III tibia fractures between March 2003 and September 2007 were reviewed. We stratified the complications related to external fixation as major, potential, and minor complications. We defined major complications as neurovascular injury, mechanical failure, septic joint, and pin tract osteomyelitis. Potential complications were defined as pins within 1 inch of the fracture, pin overpenetration (> or = 26 mm), pin without cortical purchase, and intracapsular pin placement. Minor complications were defined as pin tract infections, addition of pins or bars, and pin overpenetration (9-25 mm). "Successful application" was defined as the absence of major or potential complications. RESULTS: We recorded no major complications. There were 12 of 53 (22.6%) constructs and 21 of 228 (9.2%) pins inserted with potential complications. We detected minor complications in 27 of 53 (50.9%) constructs and 35 of 228 (15.3%) pins inserted; 41 of 53 (77.4%) constructs had no major or potential complications. CONCLUSIONS: Treatment of combat-related open tibia fractures with external fixation was 77% successful in our series. We recorded no major complications but demonstrated the possibility for technical improvement in one of the five constructs with potential complications. Despite the recorded potential and minor complications, external fixation is safe and effective as a temporary damage control in open fractures sustained in combat.

Prevalence of late amputations during the current conflicts in Afghanistan and Iraq.

During the current conflicts, over 950 soldiers have sustained a combat-related amputation. The majority of these are acute, but an unknown number are performed months to years after the initial injury. The goal of this study is to determine the prevalence of late amputations in our combat wounded. Electronic medical records and radiographs of all soldiers who had a combat-related, lower extremity injury that resulted in amputation were reviewed to confirm demographic, injury, and amputation information. Time to amputation was defined as a late amputation when it occurred more than 12 weeks following the date of injury. There were 348 major limb amputees that met inclusion criteria. Fifty-three (15.2%) amputees had a late amputation (range = 12 wk-5.5 yr). While the majority of combat-related amputations occur acutely, more than 15% occur late. This study demonstrates that further research is needed to identify predictive factors and outcomes of the late amputation.

Management of shoulder instability in in-season athletes.

Although shoulder instability is common in young athletes, there are limited prospective data to guide treatment for competitive athletes who sustain a dislocation mid-season. The management of athletes during their competitive season requires an understanding of the natural history of shoulder instability, the specific needs of the injured athlete (eg, specific sport, player position), and the duration of treatment. Rehabilitation can enable an athlete with a shoulder dislocation to return to play within 3 weeks of injury. Bracing is an option, but it can result in restricted glenohumeral motion and thereby possibly affect performance. Surgical stabilization should be considered for the athlete with recurrent instability or inability to perform; however, this frequently results in the termination of the player's season. In this article, we review the available literature to help guide physicians treating athletes with shoulder instability.

Lateral External-fixation Adjacent to Radial Nerve.

Introduction The aim of our study was to describe the injury pattern and outcomes of active-duty subjects that underwent humeral external fixation and to determine if the placement of external fixator pins outside of the radial nerve safe zones is correlated with injury to the radial nerve. Materials and methods We examined all US Service members treated with humeral external fixation at our facility from June 2005 through June 2015. The mechanism of injury, injury pattern, location of external fixation application, pre- and postoperative radial nerve function, presence or absence of radial nerve transection from injury or external fixation, anatomic location of pins in relation to the radial nerve safe zone, and final radial nerve outcomes were recorded. We defined the proximal safe zone as 5 cm distal to the acromion to 14.8 cm proximal to the lateral epicondyle, and we defined the distal safe zone as the proximal 70% of the transepicondylar width of the humerus when projected proximally from the lateral epicondyle. Results  For our study, 123 patients were identified over our date range, and 16 subjects were included with documentation regarding nerve function/injury characteristics, appropriate radiographs, and active duty status. Around 80% of injuries resulted from a blast mechanism, and 80% of injury patterns included either an intraarticular or open fracture. The radial nerve safe zone was violated in 15 of the 16 subjects (94%). The one subject with a safe construct did not sustain a nerve injury. Complete preoperative documentation on nerve function was only available for half of the subjects. Two of five subjects known to have intact function prior to external fixation had a postoperative neurologic deficit (40%). Of eight subjects with unknown radial nerve function prior to external fixation, seven subjects had full nerve function at the final follow up, and one subject had partial sensory function only. Of the three subjects with impaired preoperative radial nerve function, two made a full recovery, and the third recovered sensory function only. Around 50% of all subjects required medical retirement. Conclusion External fixation of upper extremity injuries in combat is rarely absolutely indicated, often results in the placement of pins outside of the radial nerve safe zone, and is associated with up to a 40% incidence of radial nerve injury.

Conjoint Tendon Tenotomy for Glenoid Exposure in the Setting of Previous Coracoid Transfer.

Surgical exposure of the glenoid after previous coracoid process transfer is technically challenging as a result of distorted anatomy, obliterated soft-tissue planes, and adhesive scar tissue, which poses additional risk to adjacent neurovascular structures. The purpose of this article is to present a technique for glenoid exposure following coracoid transfer that involves tenotomy of the conjoint tendon to minimize the risk for neurovascular injury while leaving the well-healed coracoid bone graft in place.

Infectious complications of open type III tibial fractures among combat casualties.

BACKGROUND: Combat is associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection. We characterize the infections seen in conjunction with combat-associated type III tibial fractures. METHODS: We performed a retrospective medical records review to identify US military service members wounded in Iraq or Afghanistan with open diaphyseal tibial fractures who were admitted to our facility (Brooke Army Medical Center, Fort Sam Houston, Texas) between March 2003 and September 2006. RESULTS: Of the 62 patients with open tibial fractures who were identified in our initial search, 40 had fractures that met our inclusion criteria as type III diaphyseal tibial fractures. Three patients were excluded because their fractures were managed with early limb amputation, and 2 were excluded because of incomplete follow-up records. Twenty-seven of these 35 patients had at least 1 organism present in initial deep-wound cultures that were performed at admission to the hospital. The pathogens that were identified most frequently were Acinetobacter, Enterobacter species, and Pseudomonas aeruginosa. Thirteen of the 35 patients had union times of >9 months that appeared to be associated with infection. None of the gram-negative bacteria identified in the initial wound cultures were recovered again at the time of a second operation; however, all patients had at least 1 staphylococcal organism. One patient had an organism present during initial culture and in the nonunion wound; this organism was a methicillin-resistant Staphylococcus aureus strain that was inadvertently not treated. Five of 35 patients ultimately required limb amputation, with infectious complications cited as the reason for amputation in 4 of these cases. CONCLUSIONS: Combat-associated type III tibial fractures are predominantly associated with infections due to gram-negative organisms, and these infections are generally successfully treated. Recurrent infections are predominantly due to staphylococci.