Magnetic Resonance Imaging Indirect Signs for Anterior Instability of the Lateral Meniscus in Pediatric and Adolescent Patients.

BACKGROUND: Anterior instability (AI) of the LM is potentially debilitating in young patients. The use of magnetic resonance imaging (MRI) to diagnose AI is limited due to the lack of reliable and accurate MRI findings. The ability to identify AI preoperatively would potentially improve the diagnosis and treatment of this pathology. This study presents a novel MRI finding ("phantom sign") for the detection of AI of the LM and demonstrates its reliability and accuracy. METHODS: Three independent blinded reviewers performed retrospective review of preoperative MRI for all patients who underwent LM repair between July 1, 2019, and March 31, 2022, at a single center. Positive phantom sign was defined as abnormal signal intensity on MRI of the anterior horn of the LM on the coronal sequence at the anterior tibial insertion of the anterior cruciate ligament (ACL). Preoperative MRI was also evaluated for other signs of LM anterior instability. Intrarater and inter-rater reliability was assessed for rater scoring of presence of pathology on MRI. Predictive ability of each imaging finding with at least good (ICC 0.6 or above) reliability was also evaluated based on documented intraoperative findings. RESULTS: Fifty-five preoperative MRIs of arthroscopically treated LM tears were reviewed. Median age was 15 years (range 6 to 20), and 21 patients (38.2%) were female. Twenty-seven patients (49.1%) had a discoid meniscus. LM AI was present on arthroscopy for 25 knees (45.45%), and among these, 21 had discoid morphology. Interrater reliability was substantial for phantom sign (ICC 0.71, 97.5% CI: 0.55-0.82), posterior displacement (ICC 0.71, 97.5% CI: 0.55-0.82), and posterior "megahorn" (ICC 0.76, 97.5% CI: 0.62-0.85). On predictive analysis, phantom signs were 98% sensitive and 76.7% specific for LM AI. Posterior displacement and posterior megahorn were specific for AI (both 93.34%), though with limited sensitivity (32% and 28.6%, respectively). CONCLUSIONS: Phantom sign is a reliable and sensitive MRI finding for anterior instability, even in the absence of frank displacement on preoperative MRI. A positive finding should prompt a thorough arthroscopic evaluation of the anterior horn of the LM. LEVEL OF EVIDENCE: Level III-case control study.

Long-Term Health Outcomes of Limb Salvage Compared with Amputation for Combat-Related Trauma.

BACKGROUND: There are little long-term health data, particularly in terms of body composition and development of metabolic syndromes, to help surgeons to guide the decision between limb salvage and amputation in patients with limb-threatening trauma. The purpose of this study was to compare long-term health outcomes after high-energy lower-extremity trauma between patients who underwent attempted flap-based limb salvage or amputation. METHODS: We performed a retrospective review of servicemembers with a minimum 10-year follow-up who underwent flap-based limb salvage followed by unilateral amputation or continued limb salvage after combat-related, lower-extremity trauma between 2005 and 2011. Patient demographic characteristics, injury characteristics, and health outcomes including body mass index (BMI) and development of metabolic disease (e.g., hyperlipidemia, hypertension, heart disease, and diabetes) were compared between treatment cohorts. Adjusted BMIs were calculated for the amputation cohort to account for lost surface area. We performed multivariable and propensity score analysis to determine the likelihood of developing obesity or metabolic disease. RESULTS: In this study, 110 patients had available long-term follow-up (mean, 12.2 years) from the time of the injury. Fifty-six patients underwent limb salvage and 54 patients underwent unilateral amputation. There was no difference in preinjury BMI (p = 0.30). After adjusting for limb loss, the amputation cohort had a trend toward higher BMIs at ≥1 years after the injury, a higher rate of obesity, and a greater increase in BMI from baseline after the injury. The development of metabolic comorbidities was common after both amputation (23 [43%] of 54) and limb salvage (27 [48%] of 56). With the numbers available, we were unable to demonstrate a difference in risk for the development of hypertension, hyperlipidemia, diabetes, heart disease, or any comorbidity other than obesity (p > 0.05). CONCLUSIONS: Amputations may be medically necessary and may decrease pain, improve mobility, and/or expedite return to activity compared with limb salvage after similar injuries. However, limb loss may negatively impact metabolic regulation and may contribute to a higher risk of obesity despite beneficial effects on mobility. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Hounsfield Unit-Calculated Bone Mineral Density Loss Following Combat-Related Lower Extremity Amputations.

BACKGROUND: After combat-related lower extremity amputations, patients rapidly lose bone mineral density (BMD). As serial dual x-ray absorptiometry (DXA) scans are rarely performed in this setting, it is difficult to determine the timeline for bone loss and recovery or the role of interventions. However, a strong correlation has been demonstrated between DXA BMD and computed tomography (CT) signal attenuation. We sought to leverage multiple CT scans obtained after trauma to develop a predictive model for BMD after combat-related lower extremity amputations. METHODS: We reviewed amputations performed within the United States military between 2003 and 2016 in patients with multiple CT scans. We collected pertinent clinical information, including amputation level(s), complications, and time to weight-bearing. The primary outcome measure was the development of low BMD, estimated in Hounsfield units (HU) from CT scans with use of a previously validated method. One hundred and twenty-eight patients with 613 femoral neck CT scans were available for analysis. A least absolute shrinkage and selection operator (LASSO) multiple logistic regression analysis was applied to determine the effects of modifiable and non-modifiable variables on BMD. A random-effects model was applied to determine which factors were most predictive of low BMD and to quantify their effects. RESULTS: Both amputated and non-amputated extremities demonstrated substantial BMD loss, which stabilized approximately 3 years after the injury. Loss of BMD followed a logarithmic pattern, stabilizing after 1,000 days. On average, amputated limbs lost approximately 100 HU of BMD after 1,000 days. Other factors identified by the mixed-effects model included nonambulatory status (-33.5 HU), age at injury (-3.4 HU per year), surgical complications delaying weight-bearing (-21.3 HU), transtibial amputation (20.9 HU), and active vitamin-D treatment (-19.7 HU). CONCLUSIONS: Patients with combat-related lower extremity amputations experience an initially rapid decline in BMD in both intact and amputated limbs as a result of both modifiable and non-modifiable influences, including time to walking, amputation level, surgical complications, and age. The paradoxical association of vitamin-D supplementation with lower HU likely reflects this treatment being assigned to patients with low BMD. This model may assist with clinical decision-making prior to performing lower extremity amputation and also may assist providers with postoperative decision-making to optimize management for prophylaxis against osteoporosis. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Transosseous Equivalent Technique for Bony Bankart Repair.

Bony Bankart lesions of the anterior glenoid arise from traumatic glenohumeral instability events and can predispose persons to recurrent instability if not surgically stabilized. Large osseous fragments, when repaired anatomically, have excellent stability and functional outcomes; however, techniques to achieve this repair are often either tenuous or overcomplicated. In this technique guide, we describe a repair technique based on established biomechanical principles that achieves a reliable, anatomic glenoid articular surface. This technique can be readily applied in most bony Bankart settings using standard anterior labral repair instrumentation and implants.

Bone Homeostasis and Physiology in Normal and Orthopaedic Disease Conditions.

Some of the most common human systemic diseases-both benign and malignant-affect bone regulation, formation, and homeostasis (the cellular balance regulated by osteocytes, osteoblasts, and osteoclasts). This review discusses our current understanding of the molecular components and mechanisms that are responsible for homeostasis and interactions resulting in dysregulation (dysfunction due to the loss of the dynamic equilibrium of bone homeostasis). Knowledge of key pathways in bone biology can improve surgeon understanding, clinical recognition, and treatment of bone homeostasis-related diseases.

A Barbed Proximal Femoral Nailing System for Isolated Intertrochanteric Femur Fractures: Operative Outcomes.

Intertrochanteric femur fractures are associated with high morbidity/mortality, necessitating strategies to limit time under anesthesia, blood loss, and additional trauma while achieving maximal fixation in osteopenic bone. The Orthopedic Designs North America, Inc. Talon DistalFix Femoral Nail System uses deployable barbs to maximize axial and rotational control without distal interlock screws. The purpose of this study was to evaluate perioperative features and postoperative outcomes in patients treated with the DistalFix Femoral Nailing System for isolated intertrochanteric femur fractures. Seventy-one consecutive patients underwent intramedullary fixation for isolated intertrochanteric fractures with the DistalFix system between January 2019-July 2020. Median operative time was 35 (33 - 40) minutes. Median estimated blood loss was 125 (75 - 150) cc. Median fluoroscopy time was 2.4 (2.2 - 2.9) minutes and dosage was 27.1 (18.0 - 35.2) mGy. Union occurred in 98% of patients; none experienced implant cutout, and 81.1% returned to previous mobility. The DistalFix system achieves a high rate of union and return to function while limiting operative risk factors. (Journal of Surgical Orthopaedic Advances 32(1):036-040, 2023).

Posterior Glenoid Bone Loss and Instability: An Evidence-based Approach to Diagnosis and Management.

Posterior glenohumeral instability is an underappreciated cause of disability that may necessitate surgical intervention to allow functional glenoid restoration. However, posterior glenoid bone abnormalities, when sufficiently severe, may contribute to persistent instability despite a well-performed capsulolabral repair. Recognition and understanding of these lesions is critical to both surgical decision making and execution of the surgical plan. Numerous procedures have been described to address posterior instability including recent developments in arthroscopic grafting techniques. The purpose of this article was to provide an evidence-based strategy for diagnosis and management of posterior shoulder instability and glenoid bone loss.

A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated With Flap-Based Limb Salvage.

OBJECTIVES: To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014. INTERVENTION: We reviewed patient medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS: Early and late amputation rates, time to amputation, reason for amputation. RESULTS: 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion. CONCLUSIONS: This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Racial and Gender Diversity of Physicians Accepted to American Military Orthopaedic and Surgical Residencies: An 18-Year Analysis.

Orthopaedic surgery ranks among the least racially and gender diverse medical/surgical specialties. United States military surgeons train in military or military-funded residency positions to care for a markedly diverse population; however, the composition and diversity of these training programs have not been previously assessed. The purpose of this study was to analyze the trends of physician diversity in military orthopaedics in comparison with other surgical specialties over time. Methods: We performed a retrospective cohort study evaluating matriculation into first year of residency training in US military surgical training programs between 2002 and 2020. In total, 9,124 applicants were reviewed. We collected matriculant self-reported race/ethnicity and sex and the medical/specialty program. We considered under-represented minorities as those who reported their race as African American, Indian/Alaskan Native, and Native, other, or who reported ethnicity as Hispanic. We calculated changes in persons accepted to training positions over time and used linear regression to model trends in diversity among orthopaedic matriculating residents when compared with other surgical subspecialities over time. Results: Across all surgical subspecialities, the average change in percent women was 0.94% per year for the study period (p < 0.01). The average annual percent women entering orthopaedic surgery residency programs was 14% for the 18-year study period. Across all surgical subspecialties, the average change for accepted applicants from groups underrepresented in medicine (URiM) was 1.01% per year for the study period (p < 0.01). The average annual percent URiM entering orthopaedic surgery residency programs was 17% for the 18-year study period. The annual change of women and URiM entering military orthopaedic residencies was 0.10% and 1.52%, respectively. Conclusions: Despite statistically significant improvements, recruitment efforts as used to date fall far short of reversing sexual, racial, and ethnic disparities in military orthopaedic residencies. Orthopaedics has a lower representation of both women and physicians with minority backgrounds when compared with many surgical subspecialties. Additional interventions are still necessary to increase diversity for military orthopaedic surgeons.

Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness.

INTRODUCTION: As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. MATERIALS AND METHODS: We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. RESULTS: Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. CONCLUSION: Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

Validation of a High-Fidelity Fracture Fixation Model for Skill Acquisition in Orthopedic Surgery Residents.

OBJECTIVE: Simulation has become a widely accepted part of training and credentialing processes due to its ability to supplement technical skill acquisition outside of the operating room (OR). This project explores implementation of a bench-top simulation of open reduction with internal fixation (ORIF) as a cost-effective method for practicing and evaluating surgical skill. DESIGN, SETTING, AND PARTICIPANTS: Participants ranging from intern to attending surgeon performed ORIF using a standard fixation set and a bovine or porcine tibia/radius model. Performance was recorded and scored by blinded reviewers based on a modified global rating scale (GRS), objective structured assessment of technical skills (OSATS) procedure-specific checklist, and critical-mistakes (CM) model. We calculated Fleiss' kappa for inter-rater reliability, Cronbach's alpha for internal consistency of scoring systems, and used univariate analysis to determine the ability of this model to discriminate between training levels. We also performed a normalized performance-versus-cost analysis to characterize perceived value of this simulation compared to other modalities. RESULTS: Twenty subjects completed the fracture fixation exercise. Fleiss' kappa for all scoring systems indicated substantial inter-rater agreement (k = 0.81, 0.80, and 0.74 for GRS, OSATS, and CM, respectively). Internal consistency reliability for GRS and OSATS were high with Cronbach's alpha 0.96(95%CI 0.94-0.97) and 0.94(95%CI 0.91-0.96), respectively. Using a Kuskal-Wallis rank sum test, GRS, OSATS, and CM were found effective for measuring differences between resident levels (p < 0.001, p < 0.001, and p = 0.002, respectively). Qualitative valuation of the exercise indicated similar value for education compared to time spent in the OR and surgical skills labs. CONCLUSIONS: This benchtop surgical simulation provides quantitative measurement of operative skills progression, increases trainee familiarity with ORIF principles, and permits targeted education by senior surgeons with the goal of training safe graduates. Procedure-specific checklist grading tools reliably differentiated between training levels with high internal validity. Implementing this model may decrease training costs and accelerate skill acquisition.

Intramedullary Nailing of Humerus Fractures Using an Implant System with Internal Distal Locking and Avoiding Distal Incisions: Operative and Clinical Outcomes.

There is limited evidence to guide implant selection for humeral shaft fractures. The objective of this study was to evaluate operative differences, early outcomes, and complications associated with use of an intramedullary nailing (IMN) system without distal interlock screws and compare this to a standard humeral nailing system. We evaluated 49 consecutive patients who underwent IMN for humeral shaft fracture between 2015-2018. Patients were grouped based on implant; Stryker T2 Nail (n = 37), or ODI Talon DistalFix (n = 12), which achieves distal interference with an endocortical barb mechanism. Operative time using the T2 nail was significantly longer than DistalFix nails (90 vs. 64 minutes, p < 0.05). With the numbers available, there was no significant difference in estimated blood loss for both systems (114 vs. 97 ml, respectively; p = 0.6). Neurologic complications occurred in eight versus one patient in the T2 and DistalFix cohort, respectively. These findings may support increased shifts to implant systems that bypass distal interlocking systems for cost savings and patient/surgeon safety. (Journal of Surgical Orthopaedic Advances 31(1):012-016, 2022).

Tranexamic acid administration and pulmonary embolism in combat casualties with orthopaedic injuries.

In combat casualty care, tranexamic acid (TXA) is administered as part of initial resuscitation effort; however, conflicting data exist as to whether TXA contributes to increased risk of venous thromboembolism (VTE). The purpose of this study is to determine what factors increase risk of pulmonary embolism after combat-related orthopaedic trauma and whether administration of TXA is an independent risk factor for major thromboembolic events. SETTING: United States Military Trauma Centers. PATIENTS: Combat casualties with orthopaedic injuries treated at any US military trauma center for traumatic injuries sustained from January 2011 through December 2015. In total, 493 patients were identified. INTERVENTION: None. MAIN OUTCOME MEASURES: Occurrence of major thromboembolic events, defined as segmental or greater pulmonary embolism or thromboembolism-associated pulseless electrical activity. RESULTS: Regression analysis revealed TXA administration, traumatic amputation, acute kidney failure, and hypertension to be associated with the development of a major thromboembolic event for all models. Injury characteristics independently associated with risk of major VTE were Injury Severity Score 23 or greater, traumatic amputation, and vertebral fracture. The best performing model utilized had an area under curve  = 0.84, a sensitivity=0.72, and a specificity=0.84. CONCLUSIONS: TXA is an independent risk factor for major VTE after combat-related Orthopaedic injury. Injury factors including severe trauma, major extremity amputation, and vertebral fracture should prompt suspicion for increased risk of major thromboembolic events and increased threshold for TXA use if no major hemorrhage is present. LEVEL OF EVIDENCE: III, Prognostic Study.

Risk Factors for Distal Radius Osteotomy Nonunion.

BACKGROUND: Osteotomy-site nonunion after distal radius corrective osteotomy is a detrimental complication. This retrospective study aims to identify patient and surgical factors associated with nonunion risk to help mitigate this. The authors hypothesize that patient factors and potentially modifiable surgical factors are contributory. METHODS: Thirty-three patients who underwent corrective osteotomy of the distal radius for prior fracture malunion were identified. Radiographs and patient records were reviewed for demographics, comorbidities, nutritional status, plate position, angle and length of osteotomy correction, and graft used. The primary study outcome was osteotomy nonunion. Descriptive and bivariate statistics were used to identify covariates relevant to nonunion. Backward, stepwise logistic regression was applied to investigate the multivariate effects on outcome, and regression analysis was adjusted for confounders. RESULTS: Seven patients (21 percent) experienced nonunion after initial corrective osteotomy. Risk factors associated with nonunion included correction length of osteotomy of 5 mm or greater and prior treatment with open reduction and internal fixation. Autograft use was protective against nonunion. History of osteoporosis showed a trend toward increased risk. Angle of osteotomy correction, nutritional deficit, age, diabetes, smoking status, and obesity were not identified as risk factors by the multivariate model. CONCLUSIONS: Distraction length at the osteotomy site, graft selection, and prior internal fixation were significant risk factors for distal radius osteotomy nonunion, but other factors traditionally associated with nonunion did not appear to impact risk. The authors recommend using autograft bone augmentation, particularly when distracting the osteotomy beyond 5 mm or after prior internal fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

BACKGROUND: Flap-based limb salvage surgery balances the morbidity and complexity of soft tissue transfer against the potential benefit of preserving a functional limb when faced with a traumatized extremity with composite tissue injury. These composite tissue injuries are well suited for multidisciplinary management between orthopaedic and plastic surgeons. Thus, it makes intuitive sense that a collaborative, orthoplastic approach to flap-based limb salvage surgery can result in improved outcomes with decreased risk of flap failure and other complications, raising the question of whether this orthoplastic team approach should be the new standard of care in limb salvage surgery. QUESTIONS/PURPOSES: (1) Is there an association between increased annual institutional volume and perioperative complications to include free and local flap failure (substantial flap viability loss necessitating return to the operating room for debridement of a major portion or all of the flap or amputation)? (2) Is an integrated orthoplastic collaborative approach to managing combat-related traumatic injuries of the extremities individually associated with a decreased risk of flap failure and overall flap-related complications? (3) What other factors, such as location of injury, injury severity score, and initial inpatient length of stay, were associated with flap necrosis and flap-related complications? METHODS: We performed a retrospective review of the electronic medical records of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System's National Capital Region between January 1, 2003 and December 31, 2012. In total, 307 patients underwent 330 flap procedures. Of the 330 flaps, 59% (195) were local or pedicled flaps and 41% (135) were free flaps. Patients were primarily male (99% [303]), with a median (interquartile range) age of 24 years old (IQR 21 to 29), and 87% (267 of 307) of injuries were sustained from a blast mechanism. We collected data on patient demographics, annual case volume involving flap coverage of extremities, mechanism of injury, flap characteristics, perioperative complications, flap failure, flap revision, isolated orthopaedic management versus an integrated orthoplastic approach, and other salvage procedures. For the purposes of this study, orthoplastic management refers to operative management of flap coverage with microvascular surgeons present for soft tissue transfer after initial debridement and fixation by orthopaedic surgery. The orthoplastic management was implemented on a case-by-case basis based on individual injury characteristics and the surgeon's discretion with no formal starting point. When implemented, the orthoplastic team consisted of an orthopaedic surgeon and microvascular-trained hand surgeons and/or plastic surgeons. In all, 77% (254 of 330) of flaps were performed using this model. We considered perioperative flap complications as any complication (such as infection, hematoma, dehiscence, congestion, or necrosis) resulting in return to the operating room for re-evaluation, correction, or partial debridement of the flap. We defined flap failure as a return to the operating room for debridement of a major portion of the flap or amputation secondary to complete or near-complete loss of flap viability. Of the flap procedures, 12% (40 of 330) were classified as a failure and 14% (46 of 330) experienced complications necessitating return to the operating room. Over the study period, free flaps were not more likely to fail than pedicled flaps (11% versus 13%; p = 0.52) or have complications necessitating additional procedures (14% versus 16%; p = 0.65). RESULTS: Our multiple linear regression model demonstrated that an increased number of free flaps performed in our institution annually in any given year was associated with a lower likelihood of failure per case (r = -0.17; p = 0.03) and lower likelihood of reoperation for each flap (r = -0.34; p < 0.001), after adjusting for injury severity and team type (orthoplastic or orthopaedic only). We observed a similar relationship for pedicled flaps, with increased annual case volume associated with a decreased risk of flap failure and reoperation per case after adjusting for injury severity and team type (r = -0.21; p = 0.003 and r = -0.22; p < 0.001, respectively). Employment of a collaborative orthoplastic team approach was associated with decreased flap failures (odds ratio 0.4 [95% confidence interval 0.2 to 0.9]; p = 0.02). Factors associated with flap failure included a lower extremity flap (OR 2.7 [95% CI 1.3 to 6.2]; p = 0.01) and use of muscle flaps (OR 2.3 [95% CI 1.1 to 5.3]; p = 0.02). CONCLUSION: Although prior reports of combat-related extremity trauma have described greater salvage success with the use of pedicled flaps, these reports are biased by institutional inexperience with free tissue transfer, the lack of a coordinated multiservice effort, and severity of injury bias (the most severe injuries often result in free tissue transfer). Our institutional experience, alongside a growing body of literature regarding complex extremity trauma in the civilian setting, suggest a benefit to free tissue coverage to treat complex extremity trauma with adequate practice volume and collaboration. We demonstrated that flap failure and flap-related complications are inversely associated with institutional experience regardless of flap type. Additionally, a collaborative orthoplastic approach was associated with decreased flap failures. However, these results must be interpreted with consideration for potential confounding between the increased case volume coinciding with more frequent collaboration between orthopaedic and plastic surgeons. Given these findings, consideration of an orthoplastic approach at high-volume institutions to address soft tissue coverage in complex extremity trauma may lead to decreased flap failure rates. LEVEL OF EVIDENCE: Level III, therapeutic study.

Nerve Interface Strategies for Neuroma Management and Prevention: A Conceptual Approach Guided by Institutional Experience.

In this article, the authors propose a strategy to manage and prevent symptomatic neuromas using a combination of nerve interface approaches. By using a reconstructive paradigm, these procedures provide the components integral to organized nerve regeneration, conferring both improvements in pain and potential for myoelectric control of prostheses in the future. Given the lack of evidence at this point indicating the advantage of any single nerve interface procedure, the authors propose a management approach that maximizes physiologic restoration while limiting morbidity where possible.

IDEO energy-storing orthosis: Effects on lower extremity function and preservation.

INTRODUCTION: The Intrepid Dynamic Exoskeletal Orthosis (IDEO) brace is a custom energy-storing orthosis design meant to improve gait, stability, and function after lower extremity injury or limb salvage. Early studies demonstrated the potential for the IDEO to improve functional performance, in conjunction with its paired return to run (RTR) rehabilitation program, compared to other brace types, and an impressively decreased rate of late amputation. The current study aimed to investigate these functional and revision outcomes from our institution to determine which patients may benefit most from IDEO bracing and what factors of the IDEO design and rehabilitation program are most important for improved outcomes after lower extremity trauma and/or loss of function. METHODS: We performed a retrospective review of all patients treated with a IDEO style brace at a single military lower extremity trauma referral center between May 2003 and November 2017. We reviewed the medical records for initial diagnosis, post-orthotic rehabilitation program, IDEO use characteristics, pain, change in desire for amputation, and whether patient underwent eventual amputation. RESULTS: We identified 213 patients with 222 lower extremities treated with IDEO brace. Of these, 76 limbs were treated for combat-related injuries. At one year follow-up, use status could not be determined for 37 extremities (16.7%). Of the 185 limbs with use data available, 116 (61.1%) continued regular brace use, and 37 (15.7%) reported intermittent use. Patients diagnosed with footdrop or weakness were more likely to continue use (OR 2.33, p=0.04), while patients with a previous fusion were less likely to continue use (OR 0.45, p=0.049). Undergoing any dedicated therapy increased chances of continued use (OR 3.37, p<0.001). At final follow-up, 16 patients (7.5%) underwent delayed lower extremity amputations following IDEO treatment. Overall, 27.2% of patients who initially desired amputation eventually underwent amputation despite IDEO brace use. Patients who underwent amputation reported higher pain levels (2 versus 5, p<0.001). DISCUSSION: In select patients, the IDEO may decrease the desire for delayed amputation and permit higher levels of activity; however, its efficacy appears tied to the rehabilitative regimen, pain levels, and initial diagnosis. These findings should guide post-surgical extremity bracing prescriptions and expectations.

Epidemiology and Long-Term Outcomes of Wrist Sprains in Military Academy Cadets.

BACKGROUND: The American Society for Surgery of the Hand advises patients that symptoms after wrist sprains resolve in 6 weeks and that recovery is usually excellent; however, there is scant supporting evidence for this reassurance. PURPOSE: To describe the epidemiology and report long-term outcomes of wrist sprains. STUDY DESIGN: Descriptive epidemiology study. METHODS: The US Department of Defense Military Health System Management Analysis and Reporting Tool was queried for wrist sprain International Classification of Diseases, Ninth Revision, codes between 2005 and 2008 among US Military Academy cadets. The electronic medical records were reviewed to obtain demographic information, mechanism of injury, and patient characteristics. A telephone survey was conducted to collect Single Assessment Numeric Evaluation (SANE) score, the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and ability to return to full military duty. RESULTS: Of the 90 patients identified, 49 patients (50 wrists) met the final inclusion criteria. The mean patient age was 21 years, the majority were male (86%), and most sprains occurred during athletics (65%) and military activities (20%). Most patients (61%) had radiographs taken after index wrist sprain, and few (14%) underwent magnetic resonance imaging (MRI). After a mean follow-up of 10.4 years, most patients (78%) had no further wrist injury. The average SANE and QuickDASH scores were 88 and 7.5, respectively. Two patients (4%) ultimately were treated with surgical repair. Most patients (96%) were on an upper extremity profile, limiting military duty for a median of 14 days. All patients ultimately returned to full military duty. CONCLUSION: Patients with a wrist sprain diagnosis were followed for an average of 10 years. Although the majority (96%) of patients required a median of 14 days with limited upper extremity function, MRI is rarely indicated in the acute setting and most patients will never have another wrist injury and can expect excellent wrist recovery outcomes.

Risk factors for treatment failure of fracture-related infections.

OBJECTIVE: Infection after fracture fixation is a potentially devastating outcome, and surgical management is frequently unsuccessful at clearing these infections. The purpose of this study is to determine if factors can be identified that are associated with treatment failure after operative management of a deep surgical site infection. METHODS: We retrospectively reviewed the billing system at a Level I trauma center between March 2006 and December 2015. We identified 451 patients treated for deep surgical site infection after fracture fixation at our center. A multivariate regression analysis was then performed to evaluate for factors associated with treatment failure. RESULTS: Mean follow-up was 2.3 years. One hundred fifty-six patients (35%) failed initial surgical management. Risk factors associated with treatment failure included initial culture results positive for polymicrobial organisms (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.4), removal of implants (OR, 1.9; 95% CI, 1.2-2.9), or Gustilo-Anderson IIIB/IIIC injury (OR, 2.0; 95% CI, 1.1-3.7). Increased body mass index and fulfilling the criteria to have a methicillin-resistant Staphylococcus aureus (MRSA) nasal swab screening showed a trend toward increased risk of failure. CONCLUSION: Treatment failure after deep surgical site infection was relatively common. Three distinct factors (polymicrobial infection, removal of implants, and IIIB/C fracture) were associated with failure to eradicate the infection in the first series of surgeries and antibiotics. These data might help guide clinicians as they counsel patients on the risk of treatment failure and might focus efforts to improve treatment toward patients at higher risk of treatment failure.