Orthopaedic knee scooter-related injury: prevalence and patient safety perception in a prospective cohort with exploratory risk factor analysis.

BACKGROUND: There is a paucity of research investigating the harms associated with orthopaedic knee scooter (OKS) use and patient safety perceptions. This prospective study aimed to define the prevalence of OKS-related injuries, describe the patient perceptions of OKS safety, and identify potential risk factors. METHODS: This study was conducted at a single foot and ankle fellowship-trained surgeon's community-based clinic from 6/2020 to 4/2021 and enrolled 134 patients. Our primary outcome was an OKS-related event (injury or fall) and informed an a priori power analysis. Point estimate of association magnitude was calculated as an odds ratio (OR) for statistically and clinically significant associations. RESULTS: There were 118 (88%) patients eligible for analysis; fourteen enrolled patients did not use OKS, and two withdrew. The prevalence of patient falls was 37% (44/118), and the prevalence of patient injury was 15% (18/118). Four percent of patients would not recommend OKS and 8% would not use an OKS again. Sedentary lifestyle increased risk (OR = 4.67, 1.52-14.35 95 CI) for OKS-related injury. CONCLUSIONS: Despite a high prevalence of patient falls (37%), there is a low prevalence of injury (15%) and a favorable perception of OKS safety. Sedentary lifestyles may be a risk factor for OKS-related injury and should be considered in the development of a risk model.

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials.

BACKGROUND: What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. METHODS: A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. RESULTS: The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. CONCLUSION: This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations. LEVEL OF EVIDENCE: Systematic review and meta-analysis of level I evidence.

Predictability of Lower Extremity Peripheral Nervous Anatomy.

Lower extremity nervous anatomy is highly variable. This study sought to determine relationships of lower extremity peripheral nerves to anatomic landmarks. Sixteen well-preserved lower extremities were dissected. The distance from each nerve point of interest to relevant landmarks was measured in standardized fashion. The sciatic nerve divided on average 26.0% ± 5% of the distance from the superior aspect of the fibula to the greater trochanter proximal to the knee joint line [Pearson correlation coefficient (PCC) D 0.764]. The superficial peroneal nerve pierced the crural fascia at an average of 28.0% ± 6% of the fibular length proximal to the lateral malleolus (PCC D 0.718). The deep peroneal nerve emerged between the tibialis anterior and extensor hallucis longus on average 2.7% ± 0.4% of the fibular length proximal to the tibiotalar joint line (PCC D 0.530). While there was substantial variability in the course of lower extremity peripheral nerves, the study found strong correlation with femur and fibula length within each specimen. (Journal of Surgical Orthopaedic Advances 26(4):206-210, 2017).

Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature. METHODS: The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients. RESULTS: The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance. CONCLUSIONS: Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype. LEVEL OF EVIDENCE: Level V-expert opinion.

Pediatric pelvic pyomyositis: initial MRI can be misleading.

Pelvic pyomyositis is an infection of the skeletal muscles around the hip joint. Fever, hip pain, limp, and leukocytosis are common; however, the clinical picture is often vague. MRI is the current gold-standard imaging for pyomyositis. No studies in the current literature have reported an unremarkable initial MRI in a patient with symptomatic pyomyositis. An adolescent female presented with symptomatic pelvic pyomyositis, but admission MRI was normal. A follow-up MRI indicated development of pelvic pyomyositis. The patient was successfully managed nonoperatively. The initial MRI in pyomyositis can be misleading. Patients should be admitted and MRI should be repeated, as indicated clinically.

Use of an Irrigation Pump System in Arthroscopic Procedures.

Since its inception, arthroscopic surgery has become widely adopted among orthopedic surgeons. It is therefore important to have an understanding of the basic principles of arthroscopy. Compared with open techniques, arthroscopic procedures are associated with smaller incisions, less structural damage, improved intra-articular visualization, less pain in the immediate postoperative period, and faster recovery for patients. Pump systems used for arthroscopic surgery have evolved over the years to provide improved intraoperative visualization. Gravity flow systems were described first and are still commonly used today. More recently, automated pump systems with pressure or dual pressure and volume control have been developed. The advantages of automated irrigation systems over gravity irrigation include a more consistent flow, a greater degree of joint distention, improved visualization especially with motorized instrumentation, decreased need for tourniquet use, a tamponade effect on bleeding, and decreased operative time. Disadvantages include the need for additional equipment with increased cost and maintenance, the initial learning curve for the surgical team, and increased risk of extra-articular fluid dissection and associated complications such as compartment syndrome. As image quality and pump systems improve, so does the list of indications including diagnostic and treatment modalities to address intra-articular pathology of the knee, shoulder, hip, wrist, elbow, and ankle joints. This article reviews the current literature and presents the history of arthroscopy, basic science of pressure and flow, types of irrigation pumps and their functions, settings, applications, and complications. [Orthopedics. 2016; 39(3):e474-e478.].

Shoulder impingement in the United States military.

BACKGROUND: Little is known about the incidence and characteristics of primary, or external, shoulder impingement in an occupationally and physically active population. A longitudinal, prospective epidemiologic database was used to determine the incidence and risk factors for shoulder subacromial impingement in the United States (U.S.) military. Our hypothesis was that shoulder impingement is influenced by age, sex, race, military rank, and branch of service. METHODS: The Defense Medical Epidemiology Database was queried for all shoulder impingement injuries using International Classification of Disease, Ninth Addition, Clinical Modification code 726.10 within a 10-year period from 1999 through 2008. An overall injury incidence was calculated, and a multivariate analysis performed among demographic groups. RESULTS: In an at-risk population of 13,768,534 person-years, we identified 106,940 cases of shoulder impingement resulting in an incidence of 7.77/1000 person-years in the U.S. military. The incidence of shoulder impingement increased with age and was highest in the group aged ≥40 years (incidence rate ratio [IRR], 4.90; 95% confidence interval [CI], 4.61-5.21), was 9.5% higher among men (IRR, 1.10, 95% CI, 1.06-1.13), and compared with service members in the Navy, those in the Air Force, Army, and Marine Corps were associated with higher rates of shoulder impingement (IRR, 1.46 [95% CI, 1.42-1.50], 1.42 [95% CI, 1.39-1.46], and 1.31 [95% CI, 1.26-1.36], respectively). CONCLUSIONS: The incidence of shoulder impingement among U.S. military personnel is 7.77/1000 person-years. An age of ≥40 years was a significant independent risk factor for injury.

Trends in the diagnosis of SLAP lesions in the US military.

PURPOSE: Shoulder pathology, particularly SLAP (superior labrum anterior-posterior) lesions, is prevalent in overhead athletes and physically active individuals. The aim of this study is to quantify the burden of SLAP lesions in the military and establish risk factors for diagnosis. METHODS: A retrospective analysis of all service members diagnosed with a SLAP lesion (International Classification of Disease, Ninth Revision code 840.70) in the Defense Medical Epidemiological Database between 2002 and 2009 was performed. Available epidemiological risk factors including age, sex, race, military rank, and branch of service were evaluated using multivariate Poisson regression analysis, and cumulative and subgroup incidence rates were calculated. RESULTS: During the study period, approximately 23,632 SLAP lesions were diagnosed among a population at risk of 11,082,738, resulting in an adjusted incidence rate of 2.13 per 1,000 person-years. The adjusted annual incidence rate for SLAP lesions increased from 0.31 cases per 1,000 person-years in 2002 to 1.88 cases per 1,000 person-years in 2009, with an average annual increase of 21.2 % (95 % CI 20.7 %, 22.0 %, p < 0.0001) during the study period. Age, sex, race, branch of military service, and military rank were independent risk factors associated with the incidence rate of SLAP lesion (p < 0.01). Male service members were over twofold more likely (IRR, 2.12; 95 % CI 2.01, 2.23) to sustain a SLAP lesion when compared with females. Increasing age category was associated with a statistically significant increase in the incidence rate for SLAP lesions in the present study (p < 0.001). After controlling for the other variables, those individuals of white race, enlisted ranks, or Marine Corps service experienced the highest incidence rates for SLAP. CONCLUSION: This is the first study to establish the epidemiology of SLAP lesions within an active military cohort in the American population. Sex, age, race, military rank, and branch of military service were all independently associated with the incidence rate of SLAP lesions in this physically active population at high risk for shoulder injury. LEVEL OF EVIDENCE: II.

Distal humerus atrophic nonunion in a child with osteogenesis imperfecta.

UNLABELLED: Atrophic nonunion of the distal humerus in children with osteogenesis imperfecta is a vexing and disabling problem. Traditional treatments, including casting, intramedullary nailing, plating and bone grafting have not been universally successful. We report on a case of successful treatment of one atrophic nonunion of the distal humerus in ad 2 year 10 month old child with type III OI who had failed more traditional treatments. The treatment used a combination of telescoping intramedullary nails, locking plate fixation and bone morphogenic protein. LEVEL OF EVIDENCE: Level IV.

Functional outcomes of hip arthroplasty in active duty military service members.

There are few reports on outcomes after hip arthroplasty in the military population despite increases among young, active patients. U.S. Army service members with coded hip arthroplasty between 2004 and 2010 were reviewed. Patient demographic variables were correlated with occupational outcomes. Of 183 patients, the occupational outcomes at a minimum 2 years postoperatively for service members undergoing primary hip arthroplasty were medically separated (n = 44, 24%), retired (n = 82, 45%), and returned to active duty (n = 57, 31%). Multivariate analysis identified that age less than 40 years [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.14, 10.12] and enlisted rank (OR, 3.63; 95% CI, 1.29, 10.20) as major independent risk factors for medical separation. Univariate analysis revealed that officer rank had an increased likelihood of postoperative combat deployment than enlisted rank (OR, 3.39; 95% CI, 1.50, 7.94). Despite encouraging results in the civilian literature, this study documents modest retention rates on active duty at a minimum of 2 years after primary hip arthroplasty.

The nature and incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009).

OBJECTIVES: This investigation sought to describe orthopaedic wounds sustained by service members deployed to Iraq or Afghanistan from 2005 to 2009. DESIGN: Retrospective review of prospective data. SETTING: : Joint Theater Trauma Registry (JTTR). PATIENTS: The 6092 musculoskeletal casualties contained in the JTTR. INTERVENTION: The JTTR was queried to identify all personnel sustaining musculoskeletal injuries in the period 2005-2009. Demographic information, injury mechanism, and nature of wounds were determined for all individuals. Deployment data for all service members were obtained through the Defense Manpower Data Center and the incidence of orthopaedic injuries and wounding patterns was assessed. MAIN OUTCOME MEASUREMENTS: Pairwise comparisons were made to identify statistically significant differences in incidence, and significant associations, between injury mechanism and injuries/wounding patterns. RESULTS: The JTTR contained data on 6092 musculoskeletal casualties with 17,177 wounds. Seventy-seven percent of all casualties sustained a musculoskeletal wound. The incidence of musculoskeletal combat casualties was 3.06 per 1000 deployed personnel per year, with fractures occurring in 3.41 per 1000 and soft-tissue wounds most commonly encountered (4.04 per 1000). Amputations represented 6% of all combat wounds. Most musculoskeletal wounds were caused by explosive blast (P < 0.001), as were nearly all traumatic amputations. CONCLUSIONS: This study represents the most complete description of the scope of orthopaedic war trauma. It also presents injury-specific incidences that have not previously been described for musculoskeletal combat casualties. Musculoskeletal casualties may occur in 3 of every 1000 personnel deployed per year. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clavicle fractures in the United States military: incidence and characteristics.

BACKGROUND: Although it is generally known that clavicle fractures represent a common injury of the shoulder girdle in the general population, the true incidence in the active duty military population is unknown. Given the implications for such injuries on the ability to perform occupation-specific tasks, determining the incidence in the U.S. military population is worthwhile. The purpose of this study was to determine the incidence of clavicle fractures in the U.S. military and to identify any demographic risk factors for injury. METHODS: We performed a query of the Defense Medical Epidemiology Database with the code from the International Classification of Diseases, Ninth Revision, for clavicle fractures for the years 1999 through 2008. An overall injury incidence was calculated, in addition to multivariate analysis, to determine independent risk factors among the following demographic considerations: sex, race, branch of military service, rank, and age. RESULTS: During the study period, a total of 12,514 clavicle fractures were documented among an at-risk population of 13,770,767 person-years for an incidence rate (IR) of 0.91 per 1,000 person-years in the U.S. Military. Males, when compared with females, were more than twice as likely to sustain a clavicle fracture (IR ratios [IRR], 2.30; 95% confidence intervals [CI], 2.12-2.49). The peak incidence of clavicle fractures occurred in the age groups of <20 and 20 to 24. Compared to black service members, the white service members were associated with significantly higher rate of clavicle fractures (IRR, 2.45; 95% CI, 2.28-2.63). The service members serving in the Marine Corps were associated with a higher IR of clavicle fractures when compared to those in the Navy (IRR, 1.44; 95% CI, 1.35-1.53). Junior enlisted service members were 34% as likely to sustain a clavicle fracture when compared to senior officers (IRR, 1.46; 95% CI, 1.34-1.60 and IRR, 1.12; 95% CI, 0.99-1.28, respectively). CONCLUSIONS: The incidence of clavicle fractures among U.S. military personnel (0.908 per 1,000 person-years) is higher than previous epidemiological reports.

Personalized adherence activity recognition via model-driven sensor data assessment.

Creation of a personalized adherence feedback loop is crucial for initiating and sustaining health behavior change. However, self reports are not sufficient to measure actual adherence. Recording and recognizing personal activities in a ubiquitous environment has thus emerged as a promising solution. In this work, we present a model-driven sensor data assessment mechanism capable of identifying high level adherence-related activity patterns from low level signals. The proposed intelligent sensing algorithm can learn from a population-based training data set and adapt quickly to an individual's exercise patterns using the acquired personal data. Upon the recognition of each activity, the system can further provide personalized feedback such as exercise coaching, fitness planning, and abnormal event detection. The resulted system demonstrates the feasibility of a portable real-time personalized adherence feedback system that could be used for advanced healthcare services.

Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device.

Pyoderma gangrenosum is a rare autoinflammatory syndrome manifested by skin lesions eventually creating ulcers. Surgical management can lead to scarring and contracture at the site of the lesion due to the pathergy phenomenon. A 43-year-old woman presented with a 5-year history of severe equinovarus deformity due to chronic pyoderma gangrenosum on her posteromedial ankle. She underwent a staged fusion. A gradual "closed" correction was performed in a Taylor spatial frame for 8 weeks in order to obviate the need for a surgical release in the area of the ulcer. She was ambulatory and full weight-bearing within 4 weeks of her frame removal. She maintained her correction with an accommodative foot orthosis until she had an uneventful tibiotalar calcaneal fusion with an intramedullary device. This case represents the success of using a Taylor spatial frame for staged fusion involving soft-tissue correction of severe, rigid equinovarus deformity due to pyoderma gangrenosum.

Incidence of physician-diagnosed osteoarthritis among active duty United States military service members.

OBJECTIVE: To examine the incidence of osteoarthritis and the influence of demographic and occupational factors associated with this condition among active duty US service members between 1999 and 2008. METHODS: To determine the total number of incident cases of osteoarthritis, the Defense Medical Surveillance System (DMSS) was queried by sex, race, age, branch of military service, and rank using code 715 of the International Classification of Diseases, Ninth Revision, Clinical Modification. Multivariable Poisson regression analysis was used to estimate incidence rates, rate ratios, and 95% confidence intervals (95% CIs) for osteoarthritis per 1,000 person-years. RESULTS: A total of 108,266 incident cases of osteoarthritis were documented in the DMSS within a population that experienced 13,768,885 person-years at risk of disease during the study period. The overall unadjusted incidence rate among all active duty US service members during the study period was 7.86 cases per 1,000 person-years. Significant demographic and occupational risk factors for osteoarthritis included sex, age, race, branch of service, and rank (P<0.001). Women experienced an adjusted incidence rate for osteoarthritis that was nearly 20% higher than that for men (rate ratio 1.19 [95% CI 1.17-1.21]). Service members ages≥40 years experienced an adjusted incidence rate for osteoarthritis that was ∼19 times higher than that for those ages<20 years (rate ratio 18.61 [95% CI 17.57-19.57]). Black service members experienced significantly higher incidence rates of osteoarthritis than those in the white and "other" race categories. CONCLUSION: Rates of osteoarthritis were significantly higher in military populations than in comparable age groups in the general population.

Unique distal clavicular fracture in an active-duty military population.

We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.

Incidence of acute traumatic patellar dislocation among active-duty United States military service members.

BACKGROUND: Although some studies have reported an increased incidence of patellar dislocations within active populations, few studies have reported incidence rates and examined risk factors for this injury. PURPOSE: To examine the incidence of patellar dislocation injuries and the influence of demographic and occupational risk factors associated with injury among active-duty United States (US) service members between 1998 and 2007. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using the Defense Medical Surveillance System, a search was performed for International Classification of Disease, 9th Revision (ICD-9) code 836.3 among all US service members on active duty during the study period. Multivariable Poisson regression analysis was used to estimate the rate of patellar dislocation per 1000 person-years at risk to injury. Incidence rates (IRs) and incidence rate ratios (IRRs) for patellar dislocation along with 95% confidence intervals (CIs) were estimated by gender, age, race, branch of military service, and rank while controlling for the other variables in the model. RESULTS: There were a total of 9299 individuals with documented patellar dislocation injuries among a population at risk of 13 443 448 person-years. The IR was 0.69 per 1000 person-years at risk. Women were 61% more likely (IRR, 1.61; 95% CI, 1.53-1.69) to sustain a patellar dislocation injury than men. Rates were highest in the youngest age group and decreased with increasing age. Service members aged <20 years were 84% more likely (IRR, 1.84; 95% CI, 1.61-2.10) to sustain a patellar dislocation injury as service members aged ≥40 years. Differences were also noted by race, service, and rank. CONCLUSION: The incidence of patellar dislocation injuries among US service members was an order of magnitude greater than that previously reported in civilian population studies. Gender, age, race, rank, and branch of military service are important risk factors related to the incidence of patellar dislocation injuries in this population.