Heterotopic Ossification Is Associated with Painful Neuromas in Transtibial Amputees Undergoing Surgical Treatment of Symptomatic Neuromas.

BACKGROUND: A relationship between nerve and osseous regeneration has been described. During the surgical treatment of symptomatic neuroma in transtibial amputees, we have noticed that heterotopic ossification (HO) depicted on preoperative radiographs appears to be associated with the location of symptomatic neuromas in both the peroneal and tibial nerve distributions. METHODS: Data were collected for transtibial amputees who underwent surgical management of symptomatic neuroma and were prospectively enrolled from 2018 through 2023. Preoperative radiographs were assessed for the presence of HO located at the distal fibula and tibia. The presence of a peroneal and/or tibial neuroma was based on findings contained within the operative reports. Pain levels were measured on a numeric rating scale (0-10). RESULTS: Sixty-five limbs of 62 amputees were include. Peroneal neuroma and presence of fibular HO (P=0.001), and tibial neuroma and presence of tibial HO (P=0.038) demonstrated an association. The odds of having a symptomatic peroneal neuroma with fibular HO present are greater than the odds of a symptomatic peroneal neuroma when fibular HO is absent (OR 9.3; 95%CI [1.9-45.6], P=0.006). Pre-operative pain scores were significantly higher for all patients with HO (P<0.001), those with fibular HO (P<0.001), and those with tibial HO (P<0.001), compared to patients without HO. CONCLUSIONS: In patients with symptomatic neuromas, preoperative pain was worse when HO was present in the transtibial amputee's residual limb. Further research on the neuroma-HO-complex in symptomatic amputees is required. LEVEL OF EVIDENCE: Therapeutic Level IV.

Radiographic detection of lateral plateau involvement in medial tibial plateau fractures (AO/OTA 41-B1.2, 1.3, 3.2 and 3.3).

PURPOSE: To assess the accuracy of radiographs in detecting the lateral plateau involvement of medial tibial plateau fractures as well as describe the impact of CT on preoperative planning for this specific fracture morphology. METHODS: Radiograph and CT imaging of patients with a Schatzker type IV tibial plateau fractures (AO/OTA 41-B1.2, B1.3 h, B2.2. B3.2, and B3.3) between January 2013 and July 2017 were reviewed by three trauma fellowship-trained orthopedic surgeons to identify fractures of the medial condyle with an intact anterolateral articular surface. RESULTS: Lateral plateau involvement was identified in 16 (37%) radiographs and 26 (61%) CT images (p = 0.051). Radiographic detection of lateral plateau involvement demonstrated a sensitivity of 62% and specificity of 100%, and radiographs were able to predict the recommendation for surgical intervention for lateral plateau involvement with a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 60% compared to recommendations based on CT imaging. Radiographs predicted a need for a separate surgical approach with PPV of 63% and NPV of 70% when compared to recommendations based on CT images. CONCLUSIONS: Radiographs are reliable in ruling in lateral plateau involvement of medial plateau fractures, but occult lateral articular extension may only be identified in CT imaging for some cases. Surgical planning may be impacted by CT imaging for this fracture morphology, but further study is warranted to evaluate the correlation between preoperative planning and clinical outcomes. LEVEL OF EVIDENCE: III.

Injury and treatment patterns of ballistic pelvic fractures by anatomic location.

INTRODUCTION: Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries. METHODS: A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality. RESULTS: Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance. CONCLUSIONS: This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement. LEVEL OF EVIDENCE: IV.

Standard Versus Low-Dose Computed Tomography for Assessment of Acetabular Fracture Reduction.

OBJECTIVE: First, to assess the impact of varying computed tomography (CT) radiation dose on surgeon assessment of postfixation acetabular fracture reduction and malpositioned implants. Second, to quantify the accuracy of CT assessments compared with the experimentally set displacement in cadaver specimens. We hypothesized that a CT dose would not affect the assessments and that CT assessments would show a high concordance with known displacement. METHODS: We created posterior wall acetabular fractures in 8 fresh-frozen cadaver hips and reduced them with varying combinations of step and gap displacement. The insertion of an intra-articular screw was randomized. Each specimen had a CT with standard (120 kV), intermediate (100 kV), and low-dose (80 kV) protocols, with and without metal artifact reduction postprocessing. Reviewers quantified gap and step displacement, overall reduction, quality of the scan, and identified intra-articular implants. RESULTS: There were no significant differences between the CT dose protocols for assessment of gap, step, overall displacement, or the presence of intra-articular screws. Reviewers correctly categorized displacement as anatomic (0-1 mm), imperfect (2-3 mm), or poor (>3 mm) in 27.5%-57.5% of specimens. When the anatomic and imperfect categories were condensed into a single category, these scores improved to 52.5%-82.5%. Intra-articular screws were correctly identified in 56.3% of cases. Interobserver reliability was poor or moderate for all items. Reviewers rated the quality of most scans as "sufficient" (60.0%-72.5%); reviewers more frequently rated the low-dose CT as "inferior" (30.0%) and the standard dose CT as "excellent" (25%). CONCLUSION: A CT dose did not affect assessment of displacement, intra-articular screw penetration, or subjective rating of scan quality in the setting of a fixed posterior wall fracture.

Pelvic Fracture Care.

While combat-related pelvis fractures are more commonly open, higher energy, and complex in pattern than those seen in the civilian setting, the principles of management are similar. The primary differences are related to the austere setting in which the initial management takes place, and the lack of resources typically available. Initial management consists of cessation of hemorrhage, along with the multi-disciplinary prioritized management of associated injuries, and skeletal stabilization. This is most commonly achieved with a compressive sheet or pelvic binder, with pelvic external fixation when resources allow, and debridement of open wounds as necessary. Definitive, internal fixation is delayed until the patient arrives at a higher echelon of care.

Treatment of Suspected Invasive Fungal Infection in War Wounds.

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.

Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study.

Complex, full-thickness soft tissue defects secondary to large burns, trauma and war-related injuries continue to challenge reconstructive surgeons. To achieve positive surgical outcomes in these patient populations, novel approaches are needed to restore the functional, protective and aesthetic properties of skin. Herein, we provide the first report describing the staged use of a dermal regenerate template (DRT) with a spray-on epidermal regenerative modality (spray skin) in addition to autologous split-thickness skin grafting (STSG) in non-burn trauma and compare these results with those of patients treated with DRT and STSG alone. A pilot study was performed to evaluate whether the use of spray skin technology (ReCell, Avita Medical) as an adjunct to DRT (Integra, Integra Lifesciences) and autologous skin grafting in the treatment of patients with large full-thickness soft tissue losses impacts donor site burden as well as recipient and donor site re-epithelialization. In this retrospective study, two patients who were treated with DRT and STSG alone (control group) were compared with two patients who were treated with DRT and spray skin/STSG in combination (experimental group). The mechanisms of injury, total defect and treatment sizes, time to complete re-epithelialization, lengths of follow-up, outcomes and complications were reviewed. Our group observed that using a DRT in conjunction with spray skin/STSG can reduce donor site burden and decrease time to complete healing. It can also permit greater or larger meshing ratios, while aiding in improved re-pigmentation when compared with similar wounds treated with a DRT and autologous skin grafting alone. Copyright © 2017 John Wiley & Sons, Ltd.

Light-Activated Sealing of Acellular Nerve Allografts following Nerve Gap Injury.

Introduction Photochemical tissue bonding (PTB) uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. In phase 1 of this two-phase study, nerve gaps repaired with bonded isografts were superior to sutured isografts. When autograft demand exceeds supply, acellular nerve allograft (ANA) is an alternative although outcomes are typically inferior. This study assesses the efficacy of PTB when used with ANA. Methods Overall 20 male Lewis rats had 15-mm left sciatic nerve gaps repaired using ANA. ANAs were secured using epineurial suture (group 1) or PTB (group 2). Outcomes were assessed using sciatic function index (SFI), gastrocnemius muscle mass retention, and nerve histomorphometry. Historical controls from phase 1 were used to compare the performance of ANA with isograft. Statistical analysis was performed using analysis of variance and Bonferroni all-pairs comparison. Results All ANAs had signs of successful regeneration. Mean values for SFI, muscle mass retention, nerve fiber diameter, axon diameter, and myelin thickness were not significantly different between ANA + suture and ANA + PTB. On comparative analysis, ANA + suture performed significantly worse than isograft + suture from phase 1. However, ANA + PTB was statistically comparable to isograft + suture, the current standard of care. Conclusion Previously reported advantages of PTB versus suture appear to be reduced when applied to ANA. The lack of Schwann cells and neurotrophic factors may be responsible. PTB may improve ANA performance to an extent, where they are equivalent to autograft. This may have important clinical implications when injuries preclude the use of autograft.

Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries.

Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.

A Case Report of the First Nonburn-related Military Trauma Victim Treated with Spray Skin Regenerative Therapy in Combination with a Dermal Regenerate Template.

Massive soft tissue and skin loss secondary to war-related traumas are among the most frequently encountered challenges in the care of wounded warriors. This case report outlines the first military nonburn-related trauma patient treated by a combination of regenerative modalities. Our case employs spray skin technology to an established dermal regenerate matrix. Our patient, a 29-year-old active duty male, suffered a combat blast trauma in 2010 while deployed. The patient's treatment course was complicated by a severe necrotizing fasciitis infection requiring over 100 surgical procedures for disease control and reconstruction. In secondary delayed reconstruction procedures, this triple-limb amputee underwent successful staged ventral hernia repair via a component separation technique with biologic mesh underlay although this resulted in a skin deficit of more than 600 cm2. A dermal regenerate template was applied to the abdominal wound to aid in establishing a "neodermis." Three weeks after dermal regenerate application, spray skin was applied to the defect in conjunction with a 6:1 meshed split thickness skin graft. The dermal regenerate template allowed for optimization of the wound bed for skin grafting. The use of spray skin allowed for a 6:1 mesh ratio, thus minimizing the donor-site size and morbidity. Together, this approach resulted in complete healing of a large full-thickness wound. The patient is now able to perform activities of daily living, walk without a cane, and engage in various physical activities. Overall, our case highlights the potential that combining regenerative therapies can achieve in treating severe war-related and civilian traumatic injuries.

Heterotopic Ossification following Tissue Transfer for Combat-Casualty Complex Periarticular Injuries.

BACKGROUND: Although mechanisms underlying heterotopic ossification remain unknown, certain risk factors can influence heterotopic bone formation. The purpose of this study was to determine whether flaps used in periarticular reconstruction had any effect on heterotopic ossification formation. METHODS: A retrospective review of periarticular injuries requiring flap coverage from 2003 through 2014 was performed. Flap types, Injury Severity Scores, functional outcomes, and complications were reviewed. Radiology findings were assessed to determine heterotopic ossification rates and grades. RESULTS: Three hundred eighty-nine flaps were performed for traumatic extremity coverage over the 13-year study period. Sixty-nine of these flaps were used for periarticular coverage. The rate of periarticular heterotopic ossification was 47 percent for fasciocutaneous versus 54 percent for muscle-based flap coverage (p = 0.88). There were no significant differences in Injury Severity Score (p = 0.44) or overall heterotopic ossification formation (p = 0.97) between groups; however, the grade of heterotopic ossification within muscle-based flap cohort was significantly higher (1.70 for muscle versus 1.06 for the fasciocutaneous cohort; p = 0.002). CONCLUSIONS: Combat-related trauma is associated with high rates of heterotopic ossification, with an overall formation rate exceeding 85 percent for our patients requiring periarticular flap coverage. Although no difference in the rate of heterotopic ossification formation was found between fasciocutaneous and muscle flap coverages, a significantly increased severity of heterotopic ossification was seen in periarticular muscle-based flaps. These findings suggest that flap composition might not affect the rate of heterotopic ossification formation but may have an effect on ectopic bone formation severity.

Combat-Related Hemipelvectomy: 14 Cases, a Review of the Literature and Lessons Learned.

OBJECTIVES: Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013. INTERVENTION: We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS: Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function. RESULTS: Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation. CONCLUSIONS: This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Light-Activated Sealing of Nerve Graft Coaptation Sites Improves Outcome following Large Gap Peripheral Nerve Injury.

BACKGROUND: Nerve repair using photochemically bonded human amnion nerve wraps can result in superior outcomes in comparison with standard suture. When applied to nerve grafts, efficacy has been limited by proteolytic degradation of bonded amnion during extended periods of recovery. Chemical cross-linking of amnion before bonding may improve wrap durability and efficacy. METHODS: Three nerve wraps (amnion, cross-linked amnion, and cross-linked swine intestinal submucosa) and three fixation methods (suture, fibrin glue, and photochemical bonding) were investigated. One hundred ten Lewis rats had 15-mm left sciatic nerve gaps repaired with isografts. Nine groups (n = 10) had isografts secured by one of the aforementioned wrap/fixation combinations. Positive and negative control groups (n = 10) were repaired with graft and suture and no repair, respectively. Outcomes were assessed using sciatic function index, muscle mass retention, and histomorphometry. Statistical analysis was performed using analysis of variance and the post hoc Bonferroni test (p < 0.05). RESULTS: Cross-linking improved amnion durability. Photochemically bonded cross-linked amnion recovered the greatest sciatic function index, although this was not significant in comparison with graft and suture. Photochemically bonded cross-linked amnion recovered significantly greater muscle mass (67.3 ± 4.4 percent versus 60.0 ± 5.2 percent; p = 0.02), fiber diameter, axon diameter, and myelin thickness (6.87 ± 2.23 µm versus 5.47 ± 1.70 µm; 4.51 ± 1.83 µm versus 3.50 ± 1.44 µm; and 2.35 ± 0.64 µm versus 1.96 ± 0.47 µm, respectively) in comparison with graft and suture. CONCLUSION: Light-activated sealing of cross-linked human amnion results in superior outcomes when compared with conventional suture.

Regenerative medicine applications in combat casualty care.

The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.

Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length.

BACKGROUND: A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. METHODS: A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. RESULTS: Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. CONCLUSIONS: The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

Neurovascular entrapment due to combat-related heterotopic ossification in the lower extremity.

BACKGROUND: Heterotopic ossification is the ectopic formation of mature lamellar bone in nonosseous tissue. The prevalence of heterotopic ossification following combat injuries is much higher than civilian data would suggest. In certain cases, the aberrant bone formation can envelop major neurovascular structures in the lower extremity, leading to symptomatic neurovascular entrapment. METHODS: We describe five consecutive cases of heterotopic ossification leading to symptomatic neurovascular entrapment in the lower extremity as a result of blast trauma and present our method of patient assessment, preoperative planning, and surgical excision. RESULTS: Heterotopic bone was successfully excised without neurovascular injury in all patients. At a mean of twenty months (range, eight to forty-five months) postoperatively, all patients demonstrated continued improvement of their pre-excision function. All patients who had neuropathic pain had a decrease in the pain. Those with decreased joint motion regained motion once their wounds were stable. Sensory deficits resolved before motor deficits did. There was no recurrence of clinically relevant heterotopic ossification in this series. CONCLUSIONS: Excision of heterotopic bone, particularly with concurrent neurovascular entrapment, can be associated with major short-term and long-term complications. With use of our treatment algorithm, involving careful preoperative planning and meticulous operative excision, heterotopic bone entrapping major neurovascular structures following severe extremity trauma can be safely excised with subsequent clinical improvement.