Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting.

This Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery Clinical Practice Guideline (CPG) is designed to provide guidance to the deployed provider when they are treating a combat casualty who has sustained a spine or spinal cord injury. The CPG objective for the treatment and the movement of these patients is to maintain spinal stability through transport, perform decompression when urgently needed, achieve definitive stabilization when appropriate, avoid secondary injury, and prevent deterioration of the patient's neurological condition. Thorough and accurate documentation of the patient's neurological examination is crucial to ensure appropriate management decisions are made as the patient transits through the evacuation system. The use of this CPG should be in conjunction with good clinical judgment.

Gender Disparities Within US Army Orthopedic Surgery: A Preliminary Report.

INTRODUCTION: Women account for approximately 15% of the active duty US Army, and studies show that women may be at an increased risk of musculoskeletal injury during sport and military training. Nationally, the field of orthopedic surgery comprises 14% women, lagging behind other surgical fields. Demographics for US Military orthopedic surgeons are not readily available. Similarly, demographic data of graduating medical students entering Military Medicine are not reported. We hypothesize that a gender disparity within military orthopedics will be apparent. We will compare the demographic profile of providers to our patients and hypothesize that the two groups are dissimilar. Secondarily, we examine the demographics of military medical students potentially entering orthopedics from the Uniformed Services University of the Health Sciences (USUHS) or the Health Professions Scholarship Program. METHODS: A census was formed of all US Army active duty orthopedic surgeons to include staff surgeons and residents, as well as US Army medical student graduates and orthopedic patients. RESULTS: There are 252 Army orthopedic surgeons and trainees; 26 (10.3%) are women and 226 (89.7%) are men. There were no significant demographic differences between residents and staff. Between 2014 and 2017, the 672 members of the USUHS graduating classes included 246 Army graduates. Of those, 62 (25%) were female. Army Health Professions Scholarship Program graduated 1,072 medical students, with women comprising 300 (28%) of the group. No statistical trends were seen over the 4 yr at USUHS or in Health Professions Scholarship Program. In total, 2,993 orthopedic clinic visits during the study period were by Army service members, 23.6% were women. CONCLUSION: There exists a gender disparity among US Army orthopedic surgeons, similar to that seen in civilian orthopedics. Gender equity is also lacking among medical students who feed into Army graduate medical education programs. The gender profile of our patient population is not reflected by that of providers. Because patients prefer providers of the same gender, this is a limitation to patient satisfaction and access to care for musculoskeletal injuries. Further study is underway to identify perceptions and potential causes of these disparities, including the critical perspective of our patients. In addition to the inherent benefits offered by diversity (e.g., expanding the talent pool and more perspectives for decision-making), ultimately it affords a greater ability to maintain a fit and ready force.

The effect of preoperative lumbar epidural corticosteroid injection on postoperative infection rate in patients undergoing single-level lumbar decompression.

BACKGROUND CONTEXT: Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis. Although widely used, their effect on the outcomes and complications of subsequent surgery is unclear. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs. PURPOSE: The purpose of this study is to define the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infection rates. STUDY DESIGN/SETTING: This is a retrospective case control database study (Level III study). PATIENT SAMPLE: The sample comprised all patients in the MHS who had a LECI before single-level lumbar decompression surgery from 2009 to 2014. OUTCOME MEASURES: Postoperative infection within 90 days of surgery was used as the primary outcome measure for this study. Postoperative infection was identified using the International Classification of Diseases, 9th revision (ICD-9) diagnosis codes for postoperative infection. METHODS: The Military Health System Data Repository (MDR) database was searched for all patients who underwent single-level lumbar spine decompression surgery from 2009 to 2014 using Current Procedural Terminology (CPT) codes. Current Procedural Terminology codes were used to identify the subset of patients who received preoperative LECIs. For patients receiving an injection, cohorts were established based on the timing of the preoperative injection: <30 days, 30-90 days, 91-180 days, 181-365 days, and >365 days. An age-based cohort, composed of patients 65 years of age and older, was also analyzed. A subgroup analysis of patients receiving more than one preoperative injection was performed. Postoperative infection within 90 days of surgery was identified using ICD-9 codes, and infection rates for all groups were calculated and compared with the control group who did not receive preoperative LECIs. No external funding was received for this study. RESULTS: We identified 6,535 patients (847 preoperative LECI and 5,688 control) for analysis. The overall infection rate for patients undergoing single-level lumbar decompression surgery in the MHS was 0.81%. The rate ranged from 0% to 1.57% in the injection groups, with an overall infection rate in the injection group of 1.18% versus 0.76% in the control group. Despite an increased odds ratio of 1.57 following injection, no statistically significant differences were found between the control group and any injection group based on timing of injection, patient age, or number of preoperative injections. CONCLUSIONS: The results of this study suggest that within the MHS, preoperative LECIs do not significantly increase the risk of postoperative infection after single-level lumbar decompression. If a difference does exist, it is likely small.

The effect of cervical posterior foraminotomy on segmental range of motion in the setting of total disc arthroplasty.

STUDY DESIGN: Human cadaveric biomechanical analysis. OBJECTIVE: To investigate the effect on cervical spine segmental stability that results from a posterior foraminotomy after cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: Posterior foraminotomy offers the ability to decompress cervical nerves roots while avoiding the need to extend a previous fusion or revise an arthroplasty to a fusion. However, the safety of a foraminotomy in the setting of CDA is unknown. METHODS: Segmental nondestructive range of motion (ROM) was analyzed in 9 human cadaveric cervical spine specimens. After intact testing, each specimen was sequentially tested according to the following 4 experimental groups: group 1=C5-C6 CDA, group 2=C5-C6 CDA with unilateral C5-C6 foraminotomy, group 3=C5-C6 CDA with bilateral C5-C6 foraminotomy, and group 4=C5-C6 CDA with C5-C6 and C4-C5 bilateral foraminotomy. RESULTS: No differences in ROM were found between the intact, CDA, and foraminotomy specimens at C4-C5 or C6-C7. There was a step-wise increase in C5-C6 axial rotation from the intact state (8°) to group 4 (12°), although the difference did not reach statistical significance. At C5-C6, the degree of lateral bending remained relatively constant. Flexion and extension at C5-C6 was significantly higher in the foraminotomy specimens, groups 2 (18.1°), 3 (18.6°), and 4 (18.2°), compared with the intact state, 11.2°. However, no ROM difference was found within foraminotomy groups (2-4) or between the foraminotomy groups and the CDA group (group 1), 15.3°. CONCLUSION: Our results indicate that cervical stability is not significantly decreased by the presence, number, or level of posterior foraminotomies in the setting of CDA. The addition of foraminotomies to specimens with a pre-existing CDA resulted in small and insignificant increases in segmental ROM. Therefore, biomechanically, posterior foraminotomy/foraminotomies may be considered a safe and viable option in the setting of recurrent or adjacent level radiculopathy after cervical disc replacement. LEVEL OF EVIDENCE: N/A.

Systematic review and meta-analysis of minimally invasive transforaminal lumbar interbody fusion rates performed without posterolateral fusion.

The need for posterolateral fusion (PLF) in addition to interbody fusion during minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) has yet to be established. Omitting a PLF significantly reduces overall surface area available for achieving a solid arthrodesis, however it decreases the soft tissue dissection and costs of additional bone graft. The authors sought to perform a meta-analysis to establish the fusion rate of MIS TLIF performed without attempting a PLF. We performed an extensive Medline and Ovid database search through December 2010 revealing 39 articles. Inclusion criteria necessitated that a one or two level TLIF procedure was performed through a paramedian MIS approach with bilateral posterior pedicle screw instrumentation and without posterolateral bone grafting. CT scan verified fusion rates were mandatory for inclusion. Seven studies (case series and case-controls) met inclusion criteria with a total of 408 patients who underwent MIS TLIF as described above. The mean age was 50.7 years and 56.6% of patients were female. A total of 78.9% of patients underwent single level TLIF. Average radiographic follow-up was 15.6 months. All patients had local autologous interbody bone grafting harvested from the pars interarticularis and facet joint of the approach side. Either polyetheretherketone (PEEK) or allograft interbody cages were used in all patients. Overall fusion rate, confirmed by bridging trabecular interbody bone on CT scan, was 94.7%. This meta-analysis suggests that MIS TLIF performed with interbody bone grafting alone has similar fusion rates to MIS or open TLIF performed with interbody supplemented with posterolateral bone grafting and fusion.

Comparison of functional outcomes following bridge synostosis with non-bone-bridging transtibial combat-related amputations.

BACKGROUND: The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). METHODS: A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. RESULTS: The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. CONCLUSIONS: The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation.

Blast-induced lower extremity fractures with arterial injury: prevalence and risk factors for amputation after initial limb-preserving treatment.

OBJECTIVES: The purpose of this study is to determine the rate of late (secondary) amputation and to identify risk factors for amputation in injuries that were initially treated with limb preservation on the battlefield. METHODS: A retrospective review at our institution identified 24 consecutive patients with 26 blast-induced open fractures distal to the joint that had associated arterial injuries. All injuries were initially cared for on the battlefield and during the evacuation chain of care with limb preservation protocols. All definitive orthopaedic care was provided by a single fellowship-trained orthopaedic trauma surgeon at a tertiary care stateside facility. Injury factors were analyzed based on radiographic and chart review to determine associations with amputation. RESULTS: Twenty of 26 injured limbs received an amputation for a total amputation rate of 76.9% (95% confidence interval, 57.9-88.9%). Fourteen limbs received early amputation before limb salvage attempts. Six of the 12 limbs that received limb salvage underwent late amputation. CONCLUSIONS: The rate of amputation in severe blast-induced extremity fractures combined with an arterial injury initially treated with limb preservation on the battlefield and before transfer to the definitive military treatment facility is extremely high. Blast-injured lower limbs with a combined severe bony and soft tissue injury should be carefully assessed when arterial injury is present because they may require early amputation during initial surgical care on the battlefield.

Early motion protocol for select Galeazzi fractures after radial shaft fixation.

Galeazzi fractures traditionally are treated in long arm casts with the wrist fully supinated for 6 weeks after open reduction and internal fixation. Recent literature suggests that early motion can be permitted for a subset of Galeazzi fractures. Defining a safe postoperative protocol that allows immediate elbow motion, immediate platform weight bearing, and early wrist motion might decrease elbow morbidity, increase range of motion, and improve outcomes. A retrospective review of a prospectively collected database of 26 patients at a level I trauma center was conducted. Early motion protocol was assigned to patients who were radiographically and clinically stable after plate and screw fixation. Elbow flexion and platform weight bearing were allowed immediately; increased wrist rotation was allowed at 2-week intervals. Early motion of elbow and wrist seems to be safe during postoperative rehabilitation of repaired Galeazzi fractures. The postoperative protocol might maximize elbow and wrist range of motion.

Soft tissue coverage of combat wounds.

Warfare-related open fractures with large soft tissue defects create a significant reconstructive challenge. The objective of this article is to review current and evolving treatment strategies for soft tissue coverage of warfare-induced extremity wounds. A review of previously published literature and current data evaluating combat-injured personnel requiring extremity flap reconstruction performed by a single surgeon within the National Capital Area from 2004 to 2009 was performed. Collected data reviewed included injury patterns, methods of reconstruction, and success rates. Seventy-five (59 pedicled flaps and 16 free) extremity reconstructions employing flaps (34 fasciocutaneous, 34 muscle, and 7 adipofascial) were performed in the subacute time period between 7 days and 3 months. One hundred percent of the wounds were associated with open fractures. Early postoperative infections (<6 {\it weeks from reconstruction) occurred in 10 patients (13%). Total flap loss occurred in two flaps (2.8%) and partial flap loss occurred in six flaps (8.3%). Two patients underwent early limb amputation after flap failure. Two additional patients underwent delayed amputation. Flap success was 97% and limb salvage rate was 94%. Based on the location of the extremity wounds, a reconstruction guide for flap type was created. Modern military limb reconstruction strategies in carefully selected patients with soft tissue defects have resulted in low flap loss rates and high limb salvage rates despite reconstruction in the subacute period between 7 days and 3 months. This limb salvage protocol is likely applicable in high-energy civilian motor vehicle accidents or industrial trauma when highly contaminated wounds are present.

Effective lordosis: analysis of sagittal spinal canal alignment in cervical spondylotic myelopathy.

OBJECT: Analysis of cervical sagittal deformity in patients with cervical spondylotic myelopathy (CSM) requires a thorough clinical and radiographic evaluation to select the most appropriate surgical approach. Angular radiographic measurements, which are commonly used to define sagittal deformity, may not be the most appropriate to use for surgical planning. The authors present a simple straight-line method to measure effective spinal canal lordosis and analyze its reliability. Furthermore, comparisons of this measurement to traditional angular measurements of sagittal cervical alignment are made in regards to surgical planning in patients with CSM. METHODS: Twenty preoperative lateral cervical digital radiographs of patients with CSM were analyzed by 3 independent observers on 3 separate occasions using a software measurement program. Sagittal measurements included C2-7 angles utilizing the Cobb and posterior tangent methods, as well as a straight-line method to measure effective spinal canal lordosis from the dorsal-caudal aspect of the C2-7 vertebral bodies. Analysis of variance for repeated measures or Cohen 3-way (kappa) correlation coefficient analysis was performed as appropriate to calculate the intra- and interobserver reliability for each parameter. Discrepancies in angular and effective lordosis measurements were analyzed. RESULTS: Intra- and interobserver reliability was excellent (intraclass coefficient > 0.75, kappa > 0.90) utilizing all 3 techniques. Four discrepancies between angular and effective lordotic measurements occurred in which images with a lordotic angular measurement did not have lordosis within the ventral spinal canal. These discrepancies were caused by either spondylolisthesis or dorsally projecting osteophytes in all cases. CONCLUSIONS: Although they are reliable, traditional methods used to make angular measurements of sagittal cervical spine alignment do not take into account ventral obstructions to the spinal cord. The effective lordosis measurement method provides a simple and reliable means of determining clinically significant lordosis because it accounts for both overall alignment of the cervical spine as well as impinging structures ventral to the spinal cord. This method should be considered for use in the treatment of patients with CSM.

A comparison of open versus arthroscopic harvesting of osteochondral autografts.

Osteochondral autograft transfer is a technique for treatment of traumatic and degenerative cartilage lesions. A graft in which the cartilage cap is oriented perpendicular to the long axis of the graft is ideal because it can both restore the cartilage tidemark and minimize articular step-off at the recipient site. This study determines if osteochondral harvest technique (arthroscopic versus mini-open) or donor site location affects suitable graft harvest. One hundred and twenty eight osteochondral grafts were harvested in 16 cadaver knees utilizing a 7 mm OATS chisel from four donor sites: lateral supracondylar ridge, lateral femoral condyle, lateral intercondylar notch and medial femoral condyle. Mini-open and arthroscopic harvesting techniques were equally employed. Radiographic methods were used to analyze graft perpendicularity. Statistical analysis comparing graft suitability based on technique and donor site location was performed. There were no statistically significant differences (p>0.05) in graft suitability regardless of the technique used or donor site location. 69% of arthroscopic and 56% of mini-open graft harvest were considered suitable, possessing a cartilage cap and graft axis angle that would create less than 1 mm of articular incongruity. Incongruity results when the angle between the subchondral bone plug long axis and cartilage interface is greater than 74 degrees . There is no difference in the quality of osteochondral grafts harvested from the knee regardless of technique or donor site used. Osteochondral graft diameter should be kept at or less than 7 mm because of the high percentage of unacceptable grafts with increasing chisel sizes.

Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation.

BACKGROUND: The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation. METHODS: A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed. RESULTS: A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days). CONCLUSIONS: Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

Perioperative differences between bone bridging and non-bone bridging transtibial amputations for wartime lower extremity trauma.

BACKGROUND: The distal bone bridge transtibial amputation technique requires additional intraoperative surgical steps when compared to the non-bone bridging technique. Comparative functional data is not available showing a clearly superior outcome from either technique. Identifying perioperative differences could influence a surgeon's decision regarding the technique of amputation to be performed. This study's purpose was to compare perioperative differences between bone bridging transtibial amputation and non-bone bridging amputation techniques. MATERIALS AND METHODS: A retrospective review from April 2004 to April 2007 identified 37 consecutive patients with 42 transtibial amputations as a result of wartime blast injuries. Twenty-two non-bone bridging and twenty bone bridging amputations were performed. Statistical comparisons of intraoperative time, tourniquet time, estimated blood loss, the need for postoperative transfusion and frequency of wound complications was performed. RESULTS: The bone bridging amputation technique had significantly longer operative times (178.5 vs. 112.2 minutes, p<0.0005) and tourniquet times (114.8 vs. 71.0 minutes, p<0.0005). Regardless of technique used, amputations performed within the zone of injury had a 66.7% wound complication rate (p<0.0005). There was not a statistically significant difference in reoperation for wound complications between groups when controlling for zone of injury: bone bridge (6.3%) and non-bone bridge (0.0%). Amputation closure performed within the zone of injury was a significant predictor for subsequent wound problems regardless of amputation technique. CONCLUSION: Longer operative and tourniquet times should not be considered a contraindication to utilizing the bone bridging amputation technique in younger and otherwise healthy patients. Both amputation techniques have comparable rates of short term wound complications and associated blood loss. Wound closure for traumatic amputations should not be performed through the zone of injury.