Overweight/obesity, gestational weight gain, postpartum weight retention, and maternal/neonatal complications in the military.

OBJECTIVE: The objective of this study was to examine the prevalence of overweight/obesity and excessive gestational weight gain (GWG) among military beneficiaries and to assess associations of these risk factors with maternal/neonatal complications and substantial postpartum weight retention (PPWR). METHODS: We obtained data for 48,391 TRICARE beneficiaries who gave birth in 2018 or 2019 in the United States. We used logistic regression and ANOVA to examine relationships among overweight/obesity, GWG, maternal/neonatal complications, and substantial PPWR. RESULTS: Most TRICARE beneficiaries (75%) had excessive GWG, and 42% had substantial PPWR. Dependents were less likely than active-duty women to have excessive GWG (odds ratio [OR] = 0.73, 95% CI: 0.60-0.88). Women with excessive GWG were three times more likely to have substantial PPWR (OR = 3.57, 95% CI: 3.14-4.06). Those with excessive GWG were more likely to have maternal/neonatal complications (e.g., pregnancy-induced hypertension, cesarean delivery). CONCLUSIONS: Excessive GWG is frequent among TRICARE beneficiaries, particularly active-duty personnel, and is strongly associated with costly maternal/neonatal complications. Substantial PPWR is also common in this population, with excessive GWG as a key risk factor.

Surgical management of angulated femoral intramedullary nails associated with closed fractures: A systematic review of the literature.

BACKGROUND: Femoral nail bending is a rare complication of intramedullary (IM) fixation of femoral diaphyseal fractures. Published literature regarding this injury pattern has thus far been limited to case reports or case series, thus no universally accepted surgical treatment strategy has been developed. METHODS: A systematic review was conducted using the Pubmed/MEDLINE and Scopus/EMBASE databases. A standardized template was used to extract data including author, year of publication, patient demographics, degree of angulation, mechanism of injury, time since initial procedure to reinjury, surgical treatment, and clinical outcomes. A case report from our institution was described as well. RESULTS: 27 cases in 25 reports were included in the qualitative analysis. All of the patients were males, and the ages ranged from 17 to 66 (mean age = 27.8). The degree of deformity ranged from 18 to 85° (mean 35.6), most commonly in a varus or apex anterior orientation. The nail deformities were corrected via one of six general surgical techniques: full transection of the nail, partial sectioning and manual straightening, limited corticotomy or longitudinal bone window, straightening with the assistance of a plate and reduction clamps, closed manipulation, or extraction without the need for manipulation. The fractures were then most commonly treated with revision IM nail. CONCLUSIONS: The bent IM nail is a rare and challenging injury to treat. No one technique has been identified as "the gold standard" and each case must be approached with its unique characteristics in mind.

Percutaneous Sacroiliac Screw Technique.

Remembering that preoperative planning, surgical indications, and fracture reduction are paramount for this procedure, presented here is our technique for performing percutaneous sacroiliac screws, both transiliac-transsacral and sacral style. A combination of video, still pictures, and fluoroscopy images will guide the viewer through the process we routinely use highlighting specific details. Patient positioning and intraoperative fluoroscopy imaging are critical to a successful procedure. Although inlet and outlet films remain important, we find the procedure best started on the lateral sacral view to reduce the need for start site, trajectory, and imaging position changes during the case. A cannulated pig sticker (drill guide) used with long drill tip guide wires provide improved manual control to both finding a good start site and directing the trajectory. For patient safety, sacral anatomy and safe zones are discussed as well. Using these technical points will help make this a successful procedure.

Radiographic markers of femoroacetabular impingement: correlation of herniation pit and femoral bump with a positive cross-over ratio.

Introduction. The goal of this study was to research the association of femoral bumps and herniation pits with the overlap-ratio of the cross-over sign. Methods. Pelvic X-rays and CT-scans of 2925 patients with good assessment of the anterior and the posterior acetabular wall and absence of neutral pelvic tilt were enrolled in the investigation. Finally pelvic X-rays were assessed for the presence of a positive cross-over sign, and CT-scans for a femoral bump or a herniation pit. Additionally, if a positive cross-over sign was discovered, the overlap-ratio was calculated. Results. A femoral bump was found in 53.3% (n = 1559), and a herniation pit in 27.2% (n = 796) of all hips. The overlap-ratio correlated positively with the presence of a femoral bump, while a negative correlation between the overlap-ratio and the presence of a herniation pit was found. The latter was significantly more often combined with a femoral bump than without. Conclusions. We detected an increased prevalence of femoral bump with increasing overlap-ratios of the cross-over sign indicating a relation to biomechanical stress. The observed decreased prevalence of herniation pits with increasing overlap-ratios could be explained by reduced mechanical stress due to nontightened iliofemoral ligament in the presence of retroversion of the acetabulum.

Are bilateral femoral fractures no longer a marker for death?

OBJECTIVES: To determine whether previously reported high mortality rates associated with bilateral femoral fractures have decreased over time. DESIGN: Retrospective review. SETTING: Urban academic trauma center. STUDY GROUP: 54 adults with bilateral femoral fractures treated at our center from 2000 to 2006. The 108 fractures were initially treated with external fixation (11%), reamed antegrade nailing (23%), and reamed retrograde nailing (67%). Unilateral control group: 461 patients with unilateral femoral fractures treated at our center from 2002 to 2005. INTERVENTION: Univariate analysis compared our results with those of a published historical control group from the same center approximately 15 years ago (study period, 1984-1990). MAIN OUTCOME MEASUREMENTS: Mortality rates. RESULTS: We noted marked differences between the current mortality rate associated with bilateral femoral fractures and that of the historical control group. The mortality rate decreased over time at our center for both bilateral (26%-7%, P = 0.002) and unilateral (12%-2%, P = 0.0001) fractures. Mortality rates were still significantly higher (P = 0.037) for bilateral (7%) than for unilateral (2%) fractures. CONCLUSIONS: Mortality rates and Injury Severity Scores were reduced for bilateral and unilateral femoral fractures compared with data reported 15 years ago from the same center. The improved outcome might be related in part to changes in resuscitation, triage, intensive care, and orthopaedic management of the patients. However, considering that the Injury Severity Score also significantly decreased, the improvement might have occurred because of changes in injury patterns, perhaps secondary to improved safety features in motor vehicles. LEVEL OF EVIDENCE: Prognostic level III. See instructions for authors for a complete description of levels of evidence.

Spouse abuse among United States Air Force personnel who deployed in support of Operation Iraqi Freedom/Operation Enduring Freedom.

The authors examined spouse abuse perpetration among all married U.S. Air Force personnel who deployed in support of Operation Iraqi Freedom/Operation Enduring Freedom. Using Poisson and conditional Poisson regression, they compared rates of spouse abuse perpetration predeployment and postdeployment in the population of married U.S. Air Force personnel who had a combat-related deployment between October 1, 2001 and October 31, 2008 (N = 156,296). Just over 2% (n = 3,524) of deployers perpetrated at least one substantiated incident of spouse physical or emotional abuse within the 308,197,653 days at risk for abuse during the study period. Male deployers perpetrated spouse abuse at approximately twice the rate of female deployers. Regarding changes in rates of spouse abuse perpetration postdeployment versus predeployment among all deployers, the authors found no differences overall; however, several deployer and incident-related characteristics moderated this effect. Rates of emotional abuse, mild abuse, and abuse not involving alcohol were significantly lower postdeployment, whereas rates of moderate/severe abuse and abuse involving alcohol were significantly higher postdeployment. Although the majority of U.S. Air Force deployers did not perpetrate any substantiated incidents of spouse abuse, there was variability in the impact of deployment on spouse abuse rates before versus after deployment. The finding that rates of moderate/severe spouse abuse incidents involving alcohol were higher postdeployment suggests a need for focused prevention/intervention efforts.

Acetabular fracture types vary with different acetabular version.

PURPOSE: Acetabular fractures typically occur in high energy trauma. Understanding of the various contributing biomechanical factors and trauma mechanisms is still limited. While several investigations figured out what role femoral position during impact plays in distinct fracture patterns, no data exists on the influence of acetabular version on the fracture type. Our study was carried out to clarify this issue. METHODS: Radiological data sets of 192 patients (145 male, 47 female, age 14-90 years) sustaining acetabular fractures were assessed retrospectively. The crossover ratio of the crossover sign and presence or absence of the posterior wall sign and ischial spine sign were used to determine acetabular retroversion on conventional radiographs. Acetabular version in the axial plane was measured on a computed tomography (CT) scan. Statistics were then performed to analyse the relationship between the acetabular fracture type according to the Letournel classification and acetabular version. RESULTS: A significant difference (p = 0.029) in acetabular version was found between fractures of the anterior [mean equatorial edge (EE) angle 19.93°] and posterior (mean EE angle 17.53°) acetabulum in the CT scan. No difference was shown on the measurements on conventional radiographs. CONCLUSIONS: Acetabular version in the axial plane has an influence on the acetabular fracture pattern. While more anteverted acetabula were frequently associated with anterior fracture types according to the Letournel classification, retroversion of the acetabulum was associated with posterior fracture types.

Normal values of Wiberg's lateral center-edge angle and Lequesne's acetabular index--a coxometric update.

BACKGROUND: The historical pathological cut-off values for Wiberg's lateral center-edge (LCE) angle and Lequesne's acetabular index (AI) are below 20° and above 12° for the LCE and AI, respectively. The aim of this study was to reassess these two angles more than 50 years after their introduction using a standardized conventional radiological measurement method, considering changing social habits and their associated physiological changes. METHODS: A total of 1,226 anteroposterior radiographs of the pelvis (2,452 hips) were obtained according to a strict standardized radiographic technique allowing reliable measurements of the LCE angle and the AI. RESULTS: Distributions of the LCE and AI were pronouncedly Gaussian, with mean values of 33.6° for the LCE and 4.4° for the AI. The 2.5th and 97.5th empirical percentiles were 18.1 and 48.0° for the LCE and -6.9 and 14.9° for the AI. These intervals contained 95 % of the data in our large sample. Small but statistically significant differences between the sexes and right and left hips have been demonstrated. Correlation between age and coxometric indices was low. CONCLUSION: The above findings do not conflict with the historical benchmarks. Statistical differences between sexes and between right and left hips were not clinically relevant. No conclusion can be drawn about coxometric indices and clinical manifestations of hip dysplasia.

Relationship between Wiberg's lateral center edge angle, Lequesne's acetabular index, and medial acetabular bone stock.

OBJECTIVE: Knowledge of acetabular anatomy is crucial for cup positioning in total hip replacement. Medial wall thickness of the acetabulum is known to correlate with the degree of developmental dysplasia of the hip (DDH). No data exist about the relationship of routinely used radiographic parameters such as Wiberg's lateral center edge angle (LCE-angle) or Lequesne's acetabular index (AI) with thickness of the medial acetabular wall in the general population. The aim of our study was to clarify the relationship between LCE, AI, and thickness of the medial acetabular wall. MATERIALS AND METHODS: Measurements on plain radiographs (LCE and AI) and axial CT scans (quadrilateral plate acetabular distance QPAD) of 1,201 individuals (2,402 hips) were obtained using a PACS imaging program and statistical analyses were performed. RESULTS: The mean thickness of the medial acetabulum bone stock (QPAD) was 1.08 mm (95% CI: 1.05-1.10) with a range of 0.1 to 8.8 mm. For pathological values of either the LCE (<20°) or the AI (>12°) the medial acetabular wall showed to be thicker than in radiological normal hips. The overall correlation between coxometric indices and medial acetabular was weak for LCE (r =-0.21. 95% CI [-0.25, -0.17]) and moderate for AI (r = 0.37, [0.33, 0.41]). CONCLUSIONS: We did not find a linear relationship between Wiberg's lateral center edge angle, Lequesne's acetabular index and medial acetabular bone stock in radiological normal hips but medial acetabular wall thickness increases with dysplastic indices.

Complex wounds and their management.

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Surgeon variability in the treatment of pelvic ring injuries.

Pelvic ring injuries are associated with the potential for long-term disability and high mortality rates. No well-established, definitive treatment algorithms have been presented in the literature. We evaluated agreement among surgeons in selecting treatment of pelvic ring injuries and investigated the relationship between type of injury and treatment plan. We conducted a prospective agreement analysis of pelvic ring injury images at a level I regional trauma center. Eighty-nine isolated pelvic ring disruptions were selected; they were the only injuries present on the images and were thought to comprise a variety of pelvic fracture types from a database of 1600 pelvic fractures. Sets of injury images were randomly ordered and distributed to 5 orthopedic trauma surgeons blinded to patient name, attending surgeon, date of injury, and eventual treatment. Surgeons reviewed images, independently selected preferred treatments, and classified injuries with the Young-Burgess and Tile systems. Eight weeks later, images were again randomly ordered and distributed to the same 5 orthopedic surgeons, who again independently selected preferred treatments and classified injuries. Kappa analyses of agreement among surgeons and within each surgeon over time were conducted. Analysis among surgeons' treatment plans based on radiographic assessment alone revealed a mean kappa value of 0.47, indicating moderate level of agreement. Analysis of data collected 8 weeks later yielded a mean kappa value of 0.56, representing moderate agreement within each surgeon over time. Young-Burgess and Tile classifications yielded consistent treatment plans for certain fracture types and varied plans for other types. Our results question the usefulness of the 2 classification systems for predicting treatment decisions.

Radiographic markers of acetabular retroversion: correlation of the cross-over sign, ischial spine sign and posterior wall sign.

Radiological diagnosis of acetabular retroversion is based on the presence of the cross-over sign (COS), the posterior wall sign (PWS), and prominence of the ischial spine (PRISS). The primary purpose of the study was to correlate the quantitative cross-over sign with the presence or absence of the PRISS and PWS signs. The hypothesis was that both, PRISS and PWS are associated with a higher cross-over sign ratio or higher amount of acetabular retroversion. A previous study identified 1417 patients with a positive acetabular cross-over sign. Among these, three radiological parameters were assessed: (1) the amount of acetabular retroversion, quantified as a cross-over sign ratio; (2) the presence of the PRISS sign; (3) the presence of the PWS sign. The relation of these three parameters was analysed using Fisher's exact test, ANOVA, and linear regression analysis. In hips with cross-over sign, the PRISS was present in 61.7%. A direct association between PRISS and the cross-over sign ratio (p < 0.001) was seen. The PWS was positive in 31% of the hips and was also significantly related with the cross-over sign ratio (p < 0.001). In hips with a PRISS, 39.7% had a PWS sign, which was a significant relation (p < 0.001). In patients with positive PWS, 78.8% of the cases also had a PRISS (p < 0.001). Both the PRISS and PWS signs were significantly associated with higher grade cross-over values. Both the PRISS and PWS signs as well as the coexistence of COS, PRISS, and PWS are significantly associated with higher grade of acetabular retroversion. In conjunction with the COS, the PRISS and PWS signs indicate severe acetabular retroversion. Presence and recognition of distinct radiological signs around the hip joint might raise the awareness of possible femoroacetabular impingement (FAI).

Correlation of the cross-over ratio of the cross-over sign on conventional pelvic radiographs with computed tomography retroversion measurements.

OBJECTIVE: To find a correlation between the cross-over ratio of the cross-over sign on conventional anteroposterior (AP) pelvic radiographs and retroversion measurements ('roof-edge angle' and 'equatorial-edge angle) on computed tomography (CT) scans. This would facilitate the interpretation of the cross-over sign regarding the amount of acetabular retroversion. MATERIALS AND METHODS: Correctly projected AP pelvic radiographs (2,925 hips) were examined for the presence of the cross-over sign (COS), and the overlap ratio of the COS was measured. On CT scans of the same patients the 'roof-edge angle' (RE angle) and the 'equatorial-edge angle' (EE angle) were also calculated. RESULTS: A statistically significant but only weak relationship could be found between the overlap ratio of the COS and the 'roof-edge angle' (P < 0.0001; correlation coefficient -0.486) and between this ratio and the 'equatorial-edge angle' (P < 0.0001; correlation coefficient -0.395). CONCLUSION: A relationship between the overlap ratio and orientation measurements on CT scans could be found, but it was less strong than expected.

Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and Tile classification systems.

Classification systems for pelvic ring injuries have been developed to assist in understanding the anatomy of the injury, predicting prognosis, and helping define treatment. Despite the frequent clinical use of the Young-Burgess and Tile classification systems, to our knowledge little work has been conducted to validate either system. We assessed the degree of inter- and intraobserver variability when using both the Young-Burgess and Tile classification systems and thereby assessed their validity for clinical use. Eighty-nine isolated pelvic ring disruptions were selected. Sets of injury images were randomly ordered and distributed to 5 orthopedic trauma surgeons blinded to the patients' names, attending surgeons, dates of injury, and eventual treatments. The surgeons were asked to independently classify each pelvic ring disruption based on the Young-Burgess and Tile classifications. Eight weeks later, the same images were randomly ordered and redistributed to the same 5 surgeons, who were again asked to classify the pelvic injuries. A kappa analysis was conducted to analyze agreement among surgeons. A moderate degree of agreement was shown among orthopedic trauma surgeons when using both the Young-Burgess and Tile classification systems. Intraobserver agreement was found to be substantial for the Young-Burgess classification and moderate for the Tile classification. The degree of inter- and intraobserver variability may limit the usefulness of the 2 classification systems, both clinically and for research purposes.

Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps.

BACKGROUND: Functional outcomes of lower extremity reconstruction compared with amputation have been evaluated. However, there are little comparative data among the different reconstructive options. With the recent increase in perforator flaps, we compared the functional outcomes of muscle and perforator flaps. METHODS: We conducted a retrospective review of 136 lower extremity trauma patients who underwent reconstruction with either a free muscle or perforator flap during a 7-year period. Forty-two of these patients completed the study. Patients answered the short musculoskeletal functional assessment form and supplemental questions. A physical therapist evaluated performance of physical tasks. Donor site sensation was measured with the pressure specified sensing device. Radiographic fracture union was evaluated by an orthopedic surgeon. RESULTS: Of the 42 patients enrolled, 20 had coverage with perforator flaps and 22 with muscle flaps. Quality of life and functional outcomes demonstrate no difference (p > 0.05). Ninety-three percent of patients would go through the limb salvage process to avoid amputation. Sensation at the donor site was diminished in all patients; however, the perforator flap donor site had more significant sensory loss (p = 0.005). Time to bony union (p = 0.51), union in the presence of infection (p = 0.85), and infection after flap (p = 0.87) was not related to flap type. CONCLUSION: Both muscle and perforator flaps provide vascularized coverage, which nourishes the fracture but muscle flaps pilfer a functional unit which may not be inconsequential in a patient trauma. This pilot study suggests that functional outcomes of perforator skin flaps are equal to muscle flaps and a larger prospective study is warranted.

Prevalence of acetabular dome retroversion in a mixed race adult trauma patient population.

The goals of the present investigation were to identify the prevalence of acetabular dome retroversion in a mixed race population, to quantify the average amount of cross-over ratio, and to determine normative values. The presence of the cross-over sign and its overlap ratio was assessed for 2,925 hips meeting strict radiographic criteria of the pelvic radiograph. Fifty-two percent of the hips had no cross-over sign whereas 48% had at least a minimal amount of overlap of the anterior and posterior acetabular wall. Analysis of only those hips with positive cross-over sign revealed a mean cross-over ratio of 26% +/- 11% (range: 3 to 93). Forty-two percent of the patients had no cross-over on either side, 18% on one side, and 40% on both sides. The presence of the cross-over sign is more common than previously expected. Further studies will be necessary to determine the risk of pathological abnormality and to correlate symptoms to crossover ratios. Surgery should not be based solely on the finding of a cross-over sign without clinical correlation.

Risk factors associated with pelvic fractures sustained in motor vehicle collisions involving newer vehicles.

BACKGROUND: Despite advances in automotive safety, pelvic fractures caused by motor vehicle collisions remain a significant cause of mortality, morbidity, and functional disability. This study was designed to evaluate epidemiologic and biomechanic risk factors associated with pelvic fractures resulting from motor vehicle collisions. We utilized the Crash Injury Research Engineering Network (CIREN) database to identify these risk factors in newer vehicles. METHODS: Data were prospectively collected at the ten CIREN centers from 1996 to 2005. Specific data were then abstracted on all patients, biomechanic crash characteristics, and injuries sustained. Patients involved in a frontal or near-side lateral impact with pelvic fractures were compared with those without. Univariate analysis was performed using a chi2 analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS: Of the 1,851 patients studied, 511 (27.6%) had a pelvic fracture. The overall mortality was 17%. Injury specific factors associated with pelvic fracture were higher Injury Severity Score (ISS) and fatality of the patient. Biomechanic factors associated with the risk of pelvic fracture included; no airbag deployment (p < 0.001), smaller vehicle (p = 0.05), and lateral deformation location (p < 0.001). When stratified by vehicle deformation location, logistic regression models revealed statically significant variables in a frontal impact which included; higher body mass index, higher ISS, large patient vehicle, no seatbelt use, and higher deltaV. For near-side lateral impacts, multivariate analysis revealed statistically significant variables of lower body mass index, higher ISS, female sex, small vehicle size, and higher deltaV. CONCLUSIONS: Even in newer vehicles with federally mandated safety features, pelvic fractures remain a common injury. Pelvic fractures may serve as a marker of crash severity and specific crash characteristics are associated with pelvic fractures. Lateral crashes are significantly more likely to result in a pelvic fracture and, therefore, prevention of pelvic fractures should focus on improving occupant safety in near-side lateral impacts. Recognition of other associations should lead researchers to further investigate causative factors that will ultimately result in improved vehicle design.