Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist.

Purpose: To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery. Methods: A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Results: Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function. Conclusions: Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn. Level of Evidence: Level IV, systematic review of level II-IV studies.

Integrated lower extremity trauma simulator.

Severe limb trauma is prevalent in deployed U.S. Military forces since the advent of body armor. To improve outcomes, improved pre-deployment training is urgently needed. To meet this need, Simuluition Inc. and Melerit Medical AB are expanding the capabilities of the TraumaVision Simulator, originally designed for training surgeons in internal fixation procedures, to include training in battlefield relevant trauma care for fractured femurs and compartment syndrome. Simulations are being implemented for fractured femur reduction, external fixation, measuring intercompartment pressure (ICP), and performing fasciotomies. Preliminary validation work has begun to demonstrate content and construct validity of the TraumaVision simulator. Future work will include developing a SCORMs-compliant curriculum and completing the validation studies.

Conversion from external fixation to definitive fixation: periarticular injuries.

Extremity injuries sustained by uniformed service combatants pose a significant challenge to military orthopaedic surgeons. The wounding mechanisms in Operation Iraqi Freedom and Operation Enduring Freedom consist of blasts, penetrating injuries, and blunt injuries. The mortality of warriors has decreased overall because of the improvements in head, neck, and torso body armor. Consequently, the severity of extremity wounds has increased. Because of the far-forward surgical assets (surgeons and advanced equipment), these patients are stabilized rapidly and their injured extremities are treated early (ie, revascularized, débrided, stabilized). However, multiple challenges exist in the timing of definitive reconstructive efforts once these injured service members return to military medical centers in the continental United States.

The incidence of neurovascular injury during external fixator placement without radiographic assistance for lower extremity diaphyseal fractures: a cadaveric study.

BACKGROUND: During military operations or mass casualty situations, trauma surgeons are called on to place external fixation without the use of fluoroscopy. However, the safety and efficacy of this procedure has not been investigated. METHODS: Orthopedic surgeons, with varying experience, externally stabilized 20 fractured cadaver femora and tibiae. Using Behrens' safe zones, 194 half-pins were placed without radiographic assistance. Subsequently, fluoroscopy and dissections documented pin positions. RESULTS: Of the 194 pins, there were three (1.5%) neurovascular injuries (popliteal artery trifurcation). Forty-nine percent (95 of 194) of pins were overpenetrated (greater than two threads out the second cortex), with the mean distance to neurovascular structures of 10.2 mm. The mean overpenetration was +5.2 threads (13 mm). CONCLUSION: When compared with radiography-assisted fixation, our results show the risk for neurovascular injury doubles with pin placement without fluoroscopic assistance. At less than 2%, this may be an acceptable rate in battlefield/mass casualty situations. This study also demonstrates that increased experience with standard fixation correlates to safer pin placement feel-placed fixation. In austere conditions, experienced surgeons can safely place external fixators without radiographic guidance.

Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study.

BACKGROUND: Retrograde nailing of femoral shaft fractures is an effective and increasingly more popular method of fracture fixation. However, concern remains regarding the effect of the intercondylar entry-portal location on knee function. METHODS: The optimal entry-portal location was identified in cadaver femurs. Approximating the clinical intraoperative situation, a threaded guidewire was inserted into each of 26 distal femur specimens and positioned in the center of the femoral shaft as determined by anteroposterior and lateral fluoroscopic imaging. Each guidewire was then overdrilled with a 12-mm cannulated drill bit. All entry-portal locations were recorded relative to the posterior cruciate ligament attachment and the intercondylar groove and mapped relative to the known patellofemoral contact area. RESULTS: The starting holes averaged 6.21 mm anterior to the posterior cruciate ligament attachment and 2.67 mm medial to the intercondylar groove. Overall, 100% of starting portals were located in safe areas relative to the patellofemoral contact area. CONCLUSION: In the vast majority of femurs, the optimal entry portal for retrograde femoral nailing (in line with the long axis of the femur) is located in the expected safe position, anterior to the posterior cruciate ligament insertion and slightly medial to center of the intercondylar groove. However, because of anatomic variability, the ideal starting position occasionally may be located in a patellofemoral contact area. Potential compromise of the patellofemoral contact area by the retrograde nail entry portal can and should be recognized before nailing, allowing the surgeon the option of altering the surgical technique.