Bulk Osteochondral Allograft for a Firearm Injury to the Medial Femoral Condyle in a Military Service Member: A Case Report.

A 27-year-old U.S. military active duty male sustained an accidental, self-inflicted left knee gunshot injury with an unsalvageable medial femoral condyle injury. The patient underwent bulk osteochondral allograft transplantation. Nine months post-operation, the patient was fit for full military duties with no reported functional limitations and remained on active duty. Severe knee medial femoral condyle bone loss after accidental firearm injury is uncommon. Bulk knee osteochondral allograft transplantation to the medial femoral condyle provided a successful treatment option for an active duty U.S. military member with multicompartment osteochondral defects and severe medial femoral condyle bone loss due to a gunshot injury.

Femoral Neck Stress Fractures: An Updated Review.

Femoral neck stress fractures represent a relatively rare spectrum of injuries that most commonly affect military recruits and endurance athletes. If unrecognized and if proper treatment is not initiated, this condition carries potentially devastating consequences. Patients will typically present with an insidious onset, atraumatic hip, and groin pain that is relieved with rest. The condition may be initially misdiagnosed because radiographs are often normal. Magnetic resonance imaging has demonstrated superior specificity, sensitivity, and accuracy compared with other diagnostic modalities in identifying and classifying stress fractures of the femoral neck. Treatment algorithms are based on the MRI fracture morphology and presence of an intra-articular effusion. Nonsurgical management consists of a period of non-weight-bearing followed by gradual return to activity. Surgical management consists of prophylactic fracture fixation with cannulated screws to prevent fracture progression. If left untreated, patients may progress to a complete displaced femoral neck fracture, which can be associated with complications that include nonunion, osteonecrosis of the femoral head, and long-term disability. These poor outcomes emphasize the importance of early diagnosis and treatment of incomplete femoral neck stress fractures.

Military Service Members with Major Lower Extremity Fractures Return to Running with a Passive-dynamic Ankle-foot Orthosis: Comparison with a Normative Population.

BACKGROUND: Lower extremity fractures represent a high percentage of reported injuries in the United States military and can devastate a service member's career. A passive dynamic ankle-foot orthosis (PD-AFO) with a specialized rehabilitation program was initially designed to treat military service members after complex battlefield lower extremity injuries, returning a select group of motivated individuals back to running. For high-demand users of the PD-AFO, the spatiotemporal gait parameters, agility, and quality of life is not fully understood with respect to uninjured runners. QUESTIONS/PURPOSES: Do patients who sustained a lower extremity fracture using a PD-AFO with a specialized rehabilitation program differ from uninjured service members acting as controls, as measured by (1) time-distance and biomechanical parameters associated with running, (2) agility testing (using the Comprehensive High-level Activity Mobility Predictor performance test and Four Square Step Test), and (3) the Short Musculoskeletal Function Assessment score. METHODS: We conducted a retrospective data analysis of a longitudinally collected data registry of patients using a PD-AFO from 2015 to 2017 at a single institution. The specific study cohort were patients with a unilateral lower extremity fracture who used the PD-AFO for running. Patients had to be fit with a PD-AFO, have completed rehabilitation, and have undergone a three-dimensional (3-D) running analysis at a self-selected speed at the completion of the program. Of the 90 patients who used the PD-AFO for various reasons, 10 male service members with lower extremity fractures who used a PD-AFO for running (median [range] age 29 years [22 to 41], height 1.8 meters [1.7 to 1.9], weight 91.6 kg [70 to 112]) were compared with 15 uninjured male runners in the military (median age 33 years [21 to 42], height 1.8 meters [1.7 to 1.9], weight 81.6 kg [71.2 to 98.9]). The uninjured runners were active-duty service members who voluntarily participated in a gait analysis at their own self-selected running speeds; to meet eligibility for inclusion as an uninjured control, the members had to be fit for full duty without any medical restrictions, and they had to be able to run 5 miles. The controls were then matched to the study group by age, weight, and height. The primary study outcome variables were the running time-distance parameters and frontal and sagittal plane kinematics of the trunk and pelvis during running. The Four Square Step Test, Comprehensive High-level Activity Mobility Predictor scores, and Short Musculoskeletal Function Assessment scores were analyzed for all groups as secondary outcomes. Nonparametric analyses were performed to determine differences between the two groups at p < 0.05. RESULTS: For the primary outcome, patients with a PD-AFO exhibited no differences compared with uninjured runners in median (range) running velocity (3.9 meters/second [3.4 to 4.2] versus 4.1 meters/second [3.1 to 4.8], median difference 0.2; p = 0.69), cadence (179 steps/minute [169 to 186] versus 173 steps/minute [159 to 191], median difference 5.8; p = 0.43), stride length (2.6 meters [2.4 to 2.9] versus 2.8 meters [2.3 to 3.3], median difference 0.2; p = 0.23), or sagittal plane parameters such as peak pelvic tilt (24° [15° to 33°] versus 22° [14° to 28°], median difference 1.6°; p = 0.43) and trunk forward flexion (16.2° [7.3° to 23°) versus 15.4° [4.2° to 21°), median difference 0.8°; p > 0.99) with the numbers available. For the secondary outcomes, runners with a PD-AFO performed worse in Comprehensive High-level Activity Mobility Predictor performance testing than uninjured runners did, with their four scores demonstrating a median (range) single-limb stance of 35 seconds (32 to 58) versus 60 seconds (60 to 60) (median difference 25 seconds; p < 0.001), t-test result of 15 seconds (13 to 20) versus 13 seconds (10 to 14) (median difference 2 seconds; p < 0.001), and Illinois Agility Test result of 22 seconds (20 to 25) versus 18 seconds (16 to 20) (median difference 4; p < 0.001). Edgren side step test result of 20 meters (16 to 26) versus 24 meters (16 to 29) (median difference 4 meters; p = 0.11) and the Four Square Step Test of 5.5 seconds (4.1 to 7.2) versus 4.2 seconds (3.1 to 7.3) (median difference 1.3 seconds; p = 0.39) were not different between the groups with an effect size of 0.83 and 0.75, respectively. CONCLUSION: The results of our study demonstrate that service members run with discernible differences in high-level mobility and demonstrate inferior self-reported patient functioning while having no differences in speed and biomechanics compared with their noninjured counterparts with the sample size available. This study is an early report on functional gains of highly motivated service members with major lower extremity injuries who use a PD-AFO and formalized therapy program to run. LEVEL OF EVIDENCE: Level III, therapeutic study.

Non-displaced Femoral Neck Stress Fractures in Young Adults: 7-Year Outcomes of Prophylactic Fixation Versus Nonoperative Treatment.

Retrospectively compare outcomes of prophylactic fixation to nonoperative treatment of incomplete or non-displaced femoral neck stress fractures (FNSF) in young adults. Outcomes of 82 patients (mean age 21.7 years) who were diagnosed with incomplete or non-displaced FNSFs from 2002 to 2015 were compared. Forty-one underwent prophylactic fixation; the remaining were treated without surgery. Fracture characteristics and complications were recorded. Pain scores, modified Harris Hip Scores (mHHS), and Hip Outcome Scores (HOS) were obtained and compared. The average fracture line in the operative group was 67% of the femoral neck width versus 18% in the nonoperative group (p < 0.001). There was no difference in outcome scores between the two groups. Prophylactic fixation of high-risk non-displaced FNSFs resulted in similar outcome scores to non-operative management of lower-risk variants at an average of 7.3 years follow up. No patient in either group progressed to a displaced femoral neck stress fracture. (Journal of Surgical Orthopaedic Advances 29(3):173-176, 2020).

Outcomes Following the Urgent Surgical Management of Displaced Femoral Neck Stress Fractures.

OBJECTIVES: To review the clinical course, complication rates, and mid-term functional outcomes associated with the treatment of displaced femoral neck stress fractures (FNSFs). DESIGN: Retrospective Case Series. SETTING: Military Tertiary Referral Center. PATIENTS: Twenty-one operatively treated displaced FNSFs between 2002 and 2015. INTERVENTION: Urgent reduction and fixation was performed. If nonunion developed, an intertrochanteric osteotomy was performed. MAIN OUTCOME MEASUREMENTS: Nonunion, osteonecrosis (ON) of the femoral head, conversion to arthroplasty, modified Harris Hip Score, pain score, and Hip Outcome Score (HOS). RESULTS: Two (9.1%) patients developed nonunion. Both united after revision with intertrochanteric osteotomy. ON developed in one patient (4.8%) who was converted to arthroplasty. Average pain score at final follow-up was 2.0 (range 0-5). Average Modified Harris Hip Score was 84 (range 54-100). Average HOS Activities of Daily Living subscale was 80.9 (range 45.6-100). Average HOS Sport subscale was 69.8 (range 27.8-100). Larger displacement on injury films correlated with lower Modified Harris Hip Scores (P = 0.048) and lower HOS Sports Subscale Single Assessment Numeric Evaluation (P = 0.023). The need for an open reduction trended toward being a risk factor for nonunion (P = 0.081). CONCLUSIONS: This study represents the largest series of patients undergoing urgent surgery for displaced FNSFs. Nonunion and ON is found at a similar rate to what is reported in the young traumatic literature. Pain and outcome scores compare favorably to other hip pathology in young adults. Initial injury severity is variably correlated to final outcome scores. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do Spatiotemporal Gait Parameters Improve After Pilon Fracture in Patients Who Use the Intrepid Dynamic Exoskeletal Orthosis?

BACKGROUND: Pilon fractures are high-energy fractures about the ankle observed commonly in both civilian and military trauma populations. Despite surgical management, outcomes are predictably poorly characterized by functional deficits secondary to pain and stiffness. The Intrepid Dynamic Exoskeletal Orthosis (IDEO) and Return-to-Run clinical pathway were initially designed to treat military service members after complex battlefield lower extremity injuries. The IDEO has been used to treat nonbattlefield injuries, but, to our knowledge, it has not been studied specifically among patients with pilon fractures. By studying the use of the IDEO in this patient population, we hope to learn how it might improve ambulation in the community, relieve pain, and return patients to work to better identify patients who might benefit from its use. QUESTIONS/PURPOSES: The purpose of this study was to determine whether the IDEO would improve gait parameters including velocity, cadence, stride length, and single-leg stance duration in patients with pilon fractures. Our secondary endpoints of interest were reductions in pain and return to duty. METHODS: A prospectively collected database of all active-duty IDEO users at a single institution was queried for all patients using the IDEO after a pilon fracture. Patients were included if they were using the IDEO after sustaining a surgically treated pilon fracture and had exhausted all nonoperative therapies. Exclusions were patients with an incomplete gait analysis at the two study time points. Seven patients meeting these criteria were identified. Three-dimensional gait analysis was performed two times: first wearing shoes at a self-selected speed and second after a custom-made IDEO was fabricated for the patient and completion of the Return-to-Run pathway. Patients reported their average pain while ambulating using a numeric rating scale. Gait variables of interest were velocity, cadence, stride length, and single stance time. Return to military service was assessed through the military medical record. To return to duty, a service-specific physical readiness test must be completed. RESULTS: Median gait velocity improved from 1.1 (interquartile range [IQR], 0.9-1.2) to 1.3 m/s (IQR, 1.2-1.5; p = 0.01). All other variables did not change: cadence 98.4 (IQR, 93.0-107.2) to 104.5 steps/min (IQR, 103.0-109.0; p = 0.13), affected stride length 1.3 (IQR, 1.0-1.4 m) to 1.4 m (IQR, 1.3-1.6 m; p = 0.07), and affected single stance 0.42 (IQR, 0.41-0.47) to 0.43 (IQR, 0.42-0.44; p = 0.80). Pain did not change between time points: 3 (IQR, 2-3) to 2.5 (IQR, 1-3.5; p = 0.90). Three of seven patients returned to duty. CONCLUSIONS: At self-selected walking speeds, we observed no improvements in gait parameters or pain after application of the IDEO that would likely be considered clinically important, and so the device is unlikely to be worth the cost in this setting. It is possible that for higher demand users such as elite athletes, the IDEO could have a role after severe lower extremity trauma; however, this must be considered speculative until or unless proven in future studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

Do Gait and Functional Parameters Change After Transtibial Amputation Following Attempted Limb Preservation in a Military Population?

BACKGROUND: Surgical attempts at lower limb preservation after trauma may be complicated by pain and gait disturbances, which can impact the activity level of a military service member. It is unclear how later transtibial amputation (TTA) might affect patients who elect this option after attempts at limb preservation. QUESTIONS/PURPOSES: The purposes of the study were to compare preamputation and postamputation (1) the numeric rating scale for pain and pain medication use; (2) self-reported activity level, Four Square Step Test (FSST) results, and assistive device use; and (3) spatiotemporal variables measured with instrumented gait analysis in individuals who elected TTA after multiple attempts at limb preservation. METHODS: Retrospective review revealed 10 patients with unilateral lower extremity injuries who underwent late TTA between 2008 and 2016. All patients had undergone multiple limb preservation attempts and had completed instrumented gait evaluations as part of their routine care before and after TTA. One patient was excluded as a result of short followup. The remaining nine patients (eight men, 29 ± 6 years) averaged five surgeries before amputation. Injuries were from improvised explosive devices (six), motorcycle accidents (two), and one training accident. Strict indications for amputation were pain, difficulties performing activities of daily living, limited physical function, and medication dependence. Data for the aforementioned purposes were collected by gait laboratory staff before and 8 to 17 months after amputation. Time to TTA after initial injury was 5 ± 3 years. At the start of the gait analysis study, pain was assessed at rest, activity level was recorded by patient report, and the FSST was administered. RESULTS: After TTA, there was a decrease in pain scores from 4 ± 2 to 1 ± 1 and patients using narcotics decreased from four to only one patient. Self-reported walking endurance increased from 1 ± 1 mile to 7 ± 8 miles and patients able to run increased from one patient to eight with the ninth having no desire to run but bicycled. Patient FSST times improved from 12 ± 10 seconds to 5 ± 1 seconds. No patients required assistive devices after TTA. There were improvements in velocity (108 ± 16 cm/s to 142 ± 7 cm/s), stride length (129 ± 14 cm to 154 ± 8 cm), cadence (101 ± 9 steps/min to 111 ± 7 steps/min), and step width (16 ± 3 cm to 12 ± 2 cm) between pre- and postassessments. Asymmetric single-limb stance time was measured both pre- and postamputation; this did not worsen with the increase in walking velocity. CONCLUSIONS: The findings of this study show that TTA after attempted limb preservation in a young, motivated group of service members after traumatic injuries can be successful in decreasing pain and narcotic use and can allow for high-level functional activities. Future studies will be needed to compare this cohort with patients who underwent early TTA after traumatic injury. However, we acknowledge that the resources and support structure available for this population are unique and may not be readily available to the general population. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Are Gait Parameters for Through-knee Amputees Different From Matched Transfemoral Amputees?

BACKGROUND: Through-knee amputation is a common amputation level after battlefield injuries during the medical evacuation process. However, there are limited data comparing through-knee amputation with transfemoral amputation as a definitive amputation level in terms of gait parameters. QUESTIONS/PURPOSES: (1) Does through-knee amputation result in improved gait velocity when compared with matched transfemoral amputees? (2) Do through-knee amputees have a faster gait cadence than matched transfemoral amputees? (3) Do through-knee amputees have a different stride length or stride width than matched transfemoral amputees? (4) Does through-knee amputation result in decreased work of ambulation when compared with matched transfemoral amputees? METHODS: Between January 2008 and December 2012, six male active-duty military patients who had undergone unilateral through-knee amputations as a result of trauma underwent gait studies at our institution. Of those, four of six underwent gait analysis after being able to walk for at least 3 months without assistive devices, and this group was studied here. Most through-knee amputees who were not included had elective revisions of their amputations from through-knee to a transfemoral amputation before completing 3-month gait data. Each of the amputees studied was matched to a transfemoral amputee based on height, body mass index, and contralateral amputation level resulting in a case-control study of active-duty military male amputee patients. Inclusion required complete gait data collected while walking at a self-selected pace wearing custom prosthetic devices. The through-knee amputees had a median (range) age of 32 years (23-41 years) and the transfemoral amputees had a median age of 24 years (22-27 years). Three-dimensional gait data were collected and analyzed. A power analysis found that to detect a clinically important difference (set at a change in work of ambulation of 1 J/kgm) with a p value of 0.05 and a ß set to 0.2, a study population of 56 patients per group would be required; that being said, our results on a much smaller population must be considered exploratory. RESULTS: With the numbers available, we found no differences in gait velocity when comparing through-knee (1.18 m/sec) and matched transfemoral amputees (1.20 m/sec, difference of medians = 0.02 m/sec; p = 0.964). Likewise, we found no differences in gait cadence when comparing through-knee with transfemoral amputees (104 versus 106 steps/min, respectively, difference of means 2 steps/min, p = 0.971). There was no difference in stride length or stride width when comparing through-knee (70 cm and 18 cm, respectively) with transfemoral amputees (70 cm and 19 cm, respectively; p = 0.948 and p = 0.440). With the numbers available, we did not identify a difference in the work of ambulation for through-knee amputees when compared with matched transfemoral amputees (8.3 versus 7.5 J/kg, respectively; p = 0.396). CONCLUSIONS: Based on our findings, we are unable to demonstrate any functional advantages of knee disarticulation over transfemoral amputation. Although there are theoretical advantages for maintaining an intact femur during the medical evacuation and serial débridement process, we question the utility of knee disarticulation as a definitive amputation level; however, larger numbers of patients are needed to confirm these results. LEVEL OF EVIDENCE: Level III, therapeutic study.

Femoral Neck Stress Fractures: MRI Risk Factors for Progression.

BACKGROUND: Femoral neck stress fractures are overuse injuries with devastating consequences if not diagnosed and treated appropriately. The aim of this study was to retrospectively review femoral neck stress fractures using a magnetic resonance imaging (MRI)-based protocol and to identify imaging risk factors that could predict fracture progression requiring surgical intervention. METHODS: We identified all femoral neck stress fractures treated at our institution from 2002 to 2015. Inclusion criteria for the study were unilateral pathology involving either an incomplete femoral neck stress fracture with a visualized fracture line or edema without a distinct fracture line. MRI data were evaluated for edema, fracture line percentage, and hip effusion. A surgical procedure was offered to patients with fractures with interval progression on serial MRI after 6 weeks of nonoperative treatment. RESULTS: We identified 305 patients who met inclusion criteria. Initial MRI showed edema with a fracture line in 54.4% of patients and isolated edema in 45.6% of patients. Interval MRI was performed in 194 patients at a mean time of 6 weeks, and it revealed fracture progression in 13.9% of patients. There were no significant differences in the size of the fracture line on initial MRI between the group who progressed to a surgical procedure and those who resolved with nonoperative treatment (mean [and standard deviation], 24.6% ± 8.1% [95% confidence interval (CI), 21.4% to 27.8%] and 25.5% ± 11.1% [95% CI, 22.9% to 28.1%]; p = 0.287). Of the patients who required a surgical procedure, 85.2% had an effusion on the initial MRI compared with only 26.3% of those who showed interval resolution with nonoperative treatment. Those who had a hip effusion on the initial MRI had 8 times (relative risk, 8.02 [95% CI, 2.99 to 21.5]; p < 0.0001) the risk of fracture progression to surgical fixation compared with those without a hip effusion. CONCLUSIONS: In patients with a femoral neck stress fracture and fracture line, the presence of a hip effusion on the initial MRI screening is an independent risk factor for fracture progression and early prophylactic surgical intervention should be considered. All patients with isolated edema in the femoral neck without a fracture line on the initial MRI had resolution with nonoperative treatment and did not have fracture progression toward surgical fixation. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mechanical failure of a femoral lengthening nail: a case report.

BACKGROUND: This case report describes the mechanical failure of a femoral lengthening nail in order to allow early recognition and prevent its occurrence. CASE PRESENTATION: A femoral lengthening nail was used to achieve goal distraction length over eight weeks and sustained a mechanical failure during progressive weightbearing. Re-distraction was attempted with subsequent non-weight-bearing status. Although the patient was not able to attain the original goal length, radiographs demonstrated stable shortening of the patient's right lower extremity along with early signs of incomplete regenerate bone. She eventually received exchange nailing with bone graft. CONCLUSION: Post-operative protocol and weight-bearing status should be further researched and standardized after re-evaluating the mechanical stiffness of the intramedullary nail construct.

Return to Duty in Military Members Following Surgical Treatment of Incomplete Femoral Neck Fractures.

The purpose of this study was to determine whether active duty military members treated surgically for incomplete femoral neck stress fractures (FNSFs) return to duty. A retrospective review of 53 patients was evaluated to determine the rate of return to duty (RTD) related to sex, branch of service, side of fracture, and signs of femoroacetabular impingement (FAI). Signs of FAI were measured and compared to RTD. Sixty-seven percent of the sample population did not return to duty. Eighty-three percent of Marine Corps members did not return to duty and 18% of Navy active duty members did not return to duty. This finding was statistically significant (p < .001). Average follow-up was 25 months. Surgical fixation of FNSFs does not seem to affect the ability to return to active duty; however, it did prevent progression to complete or displaced fracture in all of the study patients. (Journal of Surgical Orthopaedic Advances 27(4):312-316, 2018).

Pin Malposition in External Fixator Stabilization of Combat-Related Pelvic Fractures.

The purpose of this study was to compare the accuracy of pin placement in patients with unstable pelvic fractures undergoing either iliac crest or supra-acetabular external fixation. A retrospective review was performed of computed tomography (CT) scans and injury characteristics for all patients presenting to a North Atlantic Treaty Organization Medical Treatment Facility with data entered into the Department of Defense Trauma Registry from January 2008 to October 2013 who underwent pelvic external fixation for unstable pelvic ring injuries. Thirty-two patients were analyzed. Sixteen patients underwent damage control iliac crest-based and 16 patients underwent supra-acetabular-based external fixation. There was no significant difference in patient characteristics at presentation between the two groups. Pin malposition rate on CT scan was 50/64 (78.1%) for the iliac crest group and 3/32 (9.4%) for the supra-acetabular group. Pin malposition was correlated with increasing Injury Severity Score, Abbreviated Injury Scale (AIS) head score, and AIS face score. The review concluded that iliac crest-based external fixation has a significantly higher rate of pin malposition than supra-acetabular-based external fixation.

How High Can You Go?: Retrograde Nailing of Proximal Femur Fractures.

There are no data-supported recommendations on how proximal is too proximal for retrograde nailing (RGN). At six level 1 trauma centers, patients with femur fractures within the proximal one-third of the femur treated with RGN were included. This article describes a proximal segment capture ratio (PSCR) and nail segment capture ratio to evaluate RGN of proximal fractures. The study included 107 patients. The average follow-up was 44 weeks. There were two nonunions and three malunions. There was no significant difference between PSCR of 0.3 or less and need for secondary procedures or time to full weight bearing (p>.05). In this study, a smaller (< 0.3) PSCR was not associated with an increased number of complications. A higher Orthopaedic Trauma Association classification was predictive of malunion and increased time to union. These data demonstrate that retrograde nailing is safe and effective for the treatment of supraisthmal femur fractures.

Patient Response to an Integrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: The PRIORITI-MTF Study.

Although limb salvage is now possible for many high-energy open fractures and crush injuries to the distal tibia, ankle, hindfoot, and midfoot, orthotic options are limited. The Intrepid Dynamic Exoskeletal Orthosis (IDEO) is a custom, energy-storing carbon fiber orthosis developed for trauma patients undergoing limb salvage. The IDEO differs from other orthoses in that it allows patients with ankle weakness to have more normal ankle biomechanics and increased ankle power. This article describes the design of a study to evaluate the effectiveness of the IDEO when delivered together with a high-intensity, sports medicine-based approach to rehabilitation. It builds on earlier studies by testing the program at military treatment facilities beyond the Brooke Army Medical Center and the Center for the Intrepid where the device was developed. The PRIORITI-MTF study is a multicenter before-after program evaluation where participants at least 1 year out from a traumatic lower extremity injury serve as their own controls. Participants are evaluated before receiving the IDEO, immediately after 4 weeks of physical therapy with the IDEO and at 6 and 12 months after the completion of physical therapy. Primary outcomes include functional performance, measured using well-validated assessments of speed, agility, power, and postural stability and self-reported functioning using the Short Musculoskeletal Function Assessment (SMFA) and the Veterans Health Survey (VR-12). Secondary outcomes include pain, depression, posttraumatic stress, and satisfaction with the IDEO.

Limb Salvage With Intrepid Dynamic Exoskeletal Orthosis Versus Transtibial Amputation: A Comparison of Functional Gait Outcomes.

OBJECTIVES: To determine if there is a difference in functional gait outcomes between patients with limb injuries treated with either transtibial amputation or limb preservation with the Intrepid Dynamic Exoskeletal Orthosis. DESIGN: Retrospective prognostic study. SETTING: Tertiary referral military hospital. PATIENTS: This study included 10 transtibial amputees and 10 limb preservation patients using the Intrepid Dynamic Exoskeletal Orthosis who were matched by body mass index after excluding for nontraumatic, proximal ipsilateral, contralateral, spine, or traumatic brain injuries. Transtibial amputation patients were also excluded if they did not have a gait study between 6 and 12 months after independent ambulation. Limb preservation were excluded if they did not complete the "Return to Run" program. INTERVENTIONS: An observational study of functional outcomes using instrumented gait analysis. OUTCOME MEASURES: Spatiotemporal, kinetic (vertical ground reaction force), unified deformable power, work, and efficiency. RESULTS: Limb preservation patients walked with a significantly slower cadence (P = 0.036) and spent less time on their affected limb in stance (P = 0.045), and longer in swing (P = 0.019). Amputees had significantly increased maximum positive power in both limbs (P = 0.004 and P = 0.029) and increased maximum negative power on the unaffected limb (P = 0.035). Amputees had significantly increased positive and negative work in the affected limb (P = 0.0009 and P = 0.014) and positive work in the unaffected limb (P = 0.042). There was no significant difference in the kinetic data or efficiency. CONCLUSIONS: Limb preservation patients spend less time on their affected limb as a percentage of the gait cycle. The unified deformable power demonstrated more dynamic gait in amputees, with peak values closer to normative data. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic Ossification: A Review of Current Understanding, Treatment, and Future.

Heterotopic ossification is the formation of bone at extraskeletal sites. The incidence of heterotopic ossification in military amputees from recent operations in Iraq and Afghanistan has been demonstrated to be as high as 65%. Heterotopic ossification poses problems to wound healing, rehabilitation, and prosthetic fitting. This article details the current evidence regarding its etiology, prevention, management, and research strategies.

Rare combination of ipsilateral acetabular fracture-dislocation and pertrochanteric fracture.

Acetabular fracture-dislocations are severe injuries that require urgent closed reduction of the hip and often require surgery to restore hip stability. Other authors have described acetabular fracture-dislocations associated with femoral neck fractures, but to our knowledge, this case report is the first to describe an acetabular fracture-dislocation in association with an ipsilateral pertrochanteric fracture and subtrochanteric extension. The polytraumatized patient initially was not stable enough for prolonged surgery. Through a 3-cm anterolateral hip incision, a 5-mm Schanz screw was introduced percutaneously into the femoral head through the primary fracture site under fluoroscopic guidance. With inline traction on the leg, the Schanz screw was used to manipulate the femoral head back into the acetabular fossa. The Schanz screw was removed, the head remained reduced, and a skeletal traction pin was placed to maintain length and alignment of the pertrochanteric fracture until definitive stabilization was possible. We propose a staged treatment strategy consisting of early closed reduction of the hip, and after the patient has been stabilized, reduction and fixation of the fractures. This strategy may be useful in managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.

Antegrade versus retrograde intramedullary nailing of proximal third femur fractures.

The purpose of this study is to retrospectively review the results of proximal third femur fractures treated with retrograde nailing (RGN) and compare those results to a cohort from the same period treated with antegrade nailing (AGN). Adult patients with femur fractures within 10 cm of the lesser trochanter who were treated with intramedullary nails were reviewed. Two groups, patients treated with AGN (n = 35) and RGN (n = 34), were compiled. Demographic information, comorbidities, associated injuries, radiographic outcomes, complications, and secondary procedures were compared. There were two malunions in the AGN group and three in the RGN group. The AGN group had two nonunions while the RGN group had one. Subgroup analysis demonstrated that a higher body mass index (BMI) (p = .011) and a higher AO/OTA fracture classification (p = .019) were the only factors predictive of malunion. Regardless of starting point, there were no differences between groups in the number of secondary procedures, nonunions, malunions, or time until union.

Bone transport combined with locking bridge plate fixation for the treatment of tibial segmental defects: a report of 2 cases.

Segmental tibial bone loss, specifically in the setting of high-energy trauma, presents a challenging problem to the treating orthopaedic surgeon. These injuries are often complicated by tissue loss, poor wound healing, and infection. Many techniques of reconstruction have been advocated from bone grafting to bone transport. Transport can accomplished using Ilizarov frames, monolateral external fixators, and intramedullary devices. Although transport over an intramedullary device offers the advantage of rigidity and controlled alignment, many authors consider prolonged external fixation and history of pin tract infection to be contraindications to this technique. To our knowledge, bone segment transport used in combination with locking plate fixation has not been described for the treatment of tibial bone defects. We describe two cases of bone transport using a combination of locked plate fixation and a monolateral external fixation frame for large tibial bone defects. This technique allows for easy correction of length and alignment, stable fixation, facilitates quicker, and easier frame removal and also allows for compression of transported segment at the time of docking.