Ascertaining the Readiness of Military Orthopedic Surgeons: A Revision to the Knowledge, Skills, and Abilities Methodology.

INTRODUCTION: Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described. MATERIALS AND METHODS: All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market. RESULTS: Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets. CONCLUSIONS: The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System.

BACKGROUND: Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN: All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS: One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION: This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

Diagnosis and Management of Acute Compartment Syndrome.

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons have developed the Appropriate Use Criteria (AUC) for the Diagnosis and Management of Acute Compartment Syndrome (ACS). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care, aid decision-making, and obtain the best possible outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC for the Diagnosis and Management of ACS were derived by identifying clinical indications typical of patients suspected of an ACS in clinical practice. These indications were most often parameters observable by the clinician, including symptoms or results of diagnostic tests. The 135 patient scenarios and five treatments were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate, multidisciplinary, voting panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a nine-point scale to designate a treatment as "appropriate" (median rating, seven to nine), "may be appropriate" (median rating, four to six), or "rarely appropriate" (median rating, one to three).

Establishing an Orthopedic Program-Specific, Comprehensive Competency-Based Education Program.

BACKGROUND: Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation. MATERIALS AND METHODS: The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups. RESULTS: Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation. CONCLUSIONS: The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Assessment of an Orthopedic Surgery Rotation on Musculoskeletal Competency in Emergency Medicine Residency Training.

OBJECTIVE: To determine baseline knowledge of emergency medicine (EM) residents at 2 different residency training programs and assess if a 4-week orthopedic surgery rotation would improve musculoskeletal (MSK) knowledge as assessed by the basic competency exam (BCE). This study also sought to compare variations of the BCE to determine how emergency physicians would perform on the full 25-question assessment vs a modified 18-question test. DESIGN: Residents from 2 different EM residency training programs were given the BCE to determine baseline MSK knowledge prior to their orthopedic surgery rotations. A postrotation BCE was given to the residents from both EM training programs upon completion of their orthopedic surgery rotation. Both prerotation and postrotation tests were reviewed and scored independently by a panel of experts and later assessed by 2 independent reviewers. SETTING: San Antonio Military Medical Center, SA Tx Level I Trauma, Tertiary Care Center University of Texas Health, SA, Tx, Level 1 Trauma, Tertiary Care Center. PARTICIPANTS: A total of 54 EM residents completed both the prerotation test and pos-rotation test. RESULTS: EM residents at both programs had significantly improved test scores after an orthopedic surgery rotation. Baselines scores of PGY-2 residents were higher than PGY-1 residents. CONCLUSIONS: EM residents can improve their competency in MSK education with a 4-week rotation in orthopedic surgery. Further studies are needed to determine knowledge retention and to identify components of an optimal orthopedic rotation.

Developing a Novel Scoring System to Objectively Track Orthopaedic Resident Educational Performance and Progression.

OBJECTIVE: Objectively determining orthopedic resident competence remains difficult and lacks standardization across residency programs. We sought to develop a scoring system to measure resident educational activity to stratify participation and performance in particular aspects of training and the effect of these measures on board certification. DESIGN: A weighted scoring system (Average Resident Score, ARS) was developed using the number of logged cases, clinic notes dictated, OITE PGY percentile, case minimums met, and scholarly activity completed each academic year (AY), with clinical activity being more heavily weighted. The Resident Effectiveness Score (RES), a z-score showing the number of standard deviations from the mean, was determined using the ARS. The RES effect on the Accreditation Council for Graduate Medical Education (ACGME) Milestones and American Board of Orthopedic Surgery (ABOS) Part 1 percentile score was determined using a Spearman correlation. SETTING: Large academic orthopedic residency. PARTICIPANTS: Thirty one orthopedic residents graduating between 2011 and 2016 were included. RESULTS: The RES did not differ between classes in the same AY, nor change significantly for individual residents during their training. Milestone z-scores increased as residents progressed in their education. The RES correlated with each Milestone competency subscore. The PGY5 OITE score and achieving ACGME minimums correlated with passing ABOS Part 1 (28/31 1st time pass), but the RES did not predict passing the board examination. CONCLUSIONS: This study demonstrates a scoring system encompassing multiple facets of resident education to track resident activity and progress. The RES can be tailored to an individual program's goals and aims and help program directors identify residents not maximizing educational opportunities compared to their peers. Monitoring this score may allow tailoring of educational efforts to individual resident needs. This RES may also allow residents to measure their performance and educational accomplishments and adjust their focus to obtain competence and board certification.

Minimally Invasive Lumbopelvic Fixation for Unstable U-Type Sacral Fractures.

Multi-planar transverse, U-type, and vertical sacral fractures occur from high energy trauma or as pathologic fractures and often have associated neurologic and extremity injuries. Modern treatment algorithms fall into two broad categories: 1) percutaneous posterior pelvic fixation (iliosacral or transiliac-transsacral screws) or 2) lumbopelvic fixation. Posterior pelvic screw fixation is minimally invasive but typically requires restricted weight bearing until fracture union. In many cases, lumbopelvic fixation allows for a closed reduction and provides stability to allow full weight bearing immediately after surgery; however, this fixation is often removed in a second surgery after fracture healing. Lumbopelvic fixation was originally described as an open procedure, minimally invasive lumbopelvic fixation is a recent variation and has shown promising results with less morbidity. We present a case series of unstable U-type sacral fractures treated with minimally invasive lumbopelvic fixation with staged hardware removal to illustrate the advantages and complications associated with this new technique. Ten patients with U-type sacral fractures underwent minimally invasive lumbopelvic fixation from 2016 to 2019. Six patients underwent scheduled hardware removal an average of 3.5 (range 1.9-5.5) months after index surgery. Two patients did not undergo hardware removal due to short life expectancy and diagnosis of pathologic fractures. One patient was lost to follow-up. One patient had failed fracture reduction and went on to sacral malunion that required a late sacral extension osteotomy to restore her ability to stand upright. Final disposition of all nine patients with follow-up was normal standing upright posture and normal ambulation without assistive device. There were no late displacements on postoperative upright radiographs. Complex sacral fractures are a challenging injury that can be treated with percutaneous posterior pelvic or lumbopelvic fixation. Lumbopelvic fixation offers the advantages of closed reduction to restore pelvic incidence and immediate weight bearing but has greater surgical morbidity than percutaneous posterior pelvic fixation and often requires hardware removal. The morbidity of lumbopelvic fixation may be reduced with minimally invasive techniques. Minimally invasive lumbopelvic fixation is a treatment option to be considered for complex sacral fractures.

The Role of CT Angiography in Evaluating Lower Extremity Trauma: 157 Patient Case Series at a Military Treatment Facility.

INTRODUCTION: Physical exam and angiography have important roles in the diagnosis of traumatic lower extremity vascular injury with similar reported high rates of sensitivity and specificity. It has been previously shown that CTA is not universally indicated in the setting of acute lower extremity trauma when a reliable physical examination is obtained. As such, the purpose of this study was to determine if obtaining a CTA following physical examination altered the clinical care of patients following high-energy lower extremity trauma and the generalizability to the military population. MATERIALS AND METHODS: Retrospective review of all patients who underwent lower extremity CTA during the initial trauma evaluation at a Level 1 Trauma Center from 2007 to 2014. RESULTS: One hundred and fifty-seven patients met inclusion criteria. One hundred and seventeen patient's initial physical exam excluded limb ischemia with 67 vascular injuries on CTA (9 underwent angiogram in the OR) with no reperfusions required. 40 patients had hard signs of ischemia or ABI's <0.90, 29 had injuries on CTA, and fifteen underwent a vascular reperfusion procedure for acute vascular injury. Ten of 15 reperfusions required no further angiography after CTA. The sensitivity and negative predictive value of physical exam for needed reperfusion were both 100%. There were no instances of missed vascular injury or readmission and 53 patients were discharged directly from the emergency room after a negative CTA. CONCLUSIONS: This study suggests that physical exam alone achieves a high sensitivity for vascular injury in lower extremity trauma. Physical exam excluded all lower extremity ischemia without the need for advanced imaging. While CTA was useful to confirm and localize the source of acute vascular injury, the majority of vascular injuries identified on CTA did not affect immediate clinical care and lead to additional unnecessary procedures. However, in patients with suspected vascular injury, a negative CTA was also used as rationale for immediate discharge from the emergency department without further clinical observation. When applied to the deployed military setting the results of this study support the use of physical exam to accurately diagnose limb threatening ischemia at the time of injury or Role 1 facilities with CTA reserved for diagnosing the level of the vascular injury and for potential patient clearance prior to prolonged evacuation.

Early vs Delayed Weightbearing After Microfracture of Osteochondral Lesions of the Talus: A Prospective Randomized Trial.

BACKGROUND: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. METHODS: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. RESULTS: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. CONCLUSIONS: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years' follow-up, no statistically significant differences were seen between EWB and DWB groups. LEVEL OF EVIDENCE: Level II, prospective randomized trial.

Progressive Autonomy in the Era of Increased Supervision: AOA Critical Issues.

The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy.Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.

A Systems Biology Approach for Studying Heterotopic Ossification: Proteomic Analysis of Clinical Serum and Tissue Samples.

Heterotopic ossification (HO) refers to the abnormal formation of bone in soft tissue. Although some of the underlying processes of HO have been described, there are currently no clinical tests using validated biomarkers for predicting HO formation. As such, the diagnosis is made radiographically after HO has formed. To identify potential and novel biomarkers for HO, we used isobaric tags for relative and absolute quantitation (iTRAQ) and high-throughput antibody arrays to produce a semi-quantitative proteomics survey of serum and tissue from subjects with (HO+) and without (HO-) heterotopic ossification. The resulting data were then analyzed using a systems biology approach. We found that serum samples from subjects experiencing traumatic injuries with resulting HO have a different proteomic expression profile compared to those from the matched controls. Subsequent quantitative ELISA identified five blood serum proteins that were differentially regulated between the HO+ and HO- groups. Compared to HO- samples, the amount of insulin-like growth factor I (IGF1) was up-regulated in HO+ samples, whereas a lower amount of osteopontin (OPN), myeloperoxidase (MPO), runt-related transcription factor 2 (RUNX2), and growth differentiation factor 2 or bone morphogenetic protein 9 (BMP-9) was found in HO+ samples (Welch two sample t-test; P < 0.05). These proteins, in combination with potential serum biomarkers previously reported, are key candidates for a serum diagnostic panel that may enable early detection of HO prior to radiographic and clinical manifestations.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

OBJECTIVE: It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. DESIGN: Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. RESULTS: There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10 years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. CONCLUSIONS: Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR.

Orthopaedic Resident Surgical Case Log Disparities Observed in the Next Accreditation System.

INTRODUCTION: With the institution of the Next Accreditation System (NAS), case log procedures fundamentally changed. Unless multiple entries are made, only one procedure per case is credited for procedure counts. We hypothesized that the NAS caused notable changes in national procedure data. METHODS: Accreditation Council for Graduate Medical Education Orthopaedic Surgery Case Logs National Data Reports from 2008 to 2016 were analyzed to calculate differences in case log data before and after NAS implementation. RESULTS: In the first academic year post-NAS, the average total procedures decreased by 36%. Total procedures increased the following 2 years but still represent a decrease of >30% from pre-NAS data. An average of 580 fewer total procedures per resident were reported in the 3 years post-NAS (P = 0.001). Regression analysis showed notable decreases in credited procedures in all but two categories. CONCLUSIONS: The decrease in logged procedures with the NAS may be related to new guidance, resident logging habits, an actual decrease in surgical experience, or unknown causes, or combinations of these factors. A new baseline of case data may be emerging post-NAS. To ensure the highest quality education, NAS case logs warrant continued study to determine how the data should be used in residency education and accreditation decisions.

Use of ankle magnetic resonance imaging in the active duty military population: the results of a process improvement project.

BACKGROUND: Preventing overuse of magnetic resonance imaging (MRI) for diagnosing ankle pathology was the goal of a process improvement project at a military treatment facility. METHODS: Ordering patterns for MRI of nonorthopaedic providers and orthopaedic surgeons were evaluated over 2 separate periods. An educational initiative on appropriate use of MRI in evaluating ankle complaints was conducted between the 2 periods. RESULTS: Between October 2009 and March 2010, 230 ankle MRIs were performed at our institution, compared to 347 ankle MRIs performed between December 2012 and August 2013. A lower number of patients underwent operative procedures after the education process than before (17% versus 25%). Fellowship-trained foot and ankle surgeons produced the highest number of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phases 1 and 2 respectively). There was no change in the number of ankle MRI studies ordered each month following the educational initiative (38.3 and 38.5 for Phases 1 and 2 respectively). CONCLUSIONS: The majority of patients undergoing ankle MRI did not undergo operative intervention. Foot and ankle surgeons produce the highest number of operative patients with their MRI ordering practices. Education alone was ineffective in altering ankle MRI ordering patterns.

Being Prepared for the Next Conflict: A Case Analysis of a Military Level I Trauma Center.

BACKGROUND: As we transition to an interwar period, combat-related injuries are at their lowest levels in over a decade, yet we must continue to maintain our surgical skills and train new surgeons. During the recent wars, the importance of the treatment and care for amputations and complex extremity injuries became apparent. This study compares the number of these procedures performed during the treatment of civilian and military orthopaedic trauma patients at a Department of Defense Level I trauma center over the past 9 years. The need to evaluate this unique system is further highlighted by the recent recommendation from the National Academies of Sciences, Engineering, and Medicine's to combine civilian and military trauma systems. METHODS: Data derived through a retrospective review of electronic health records were charted and evaluated for statistically unique periods. RESULTS: There were significant fluctuations in the number of procedures performed within the military cohort, with peaks centered around 2007 and 2011-2012, whereas the number of civilian cases remained relatively steady. On average, the civilian cohort also produced a more consistent and greater number of tibia fractures than the military cohort. For the past 3 years, the civilian cohort has produced 22 more tibia fractures per quarter than the military cohort. Furthermore, although type III open tibia fractures were the most common classification within the military cohort, the civilian cohort provided comparable numbers of type III open fractures despite only being the second most common fracture classification in the civilian cohort. In fact, the civilian volume outpaced the military cohort the past 3 years in this metric. More importantly, the military cohort produced 6 type III fractures in 2013, and 3 in 2014, whereas the civilian cohort produced 14 and 25, respectively, during those years. DISCUSSION/IMPACT/RECOMMENDATIONS: Fluctuations in the military cohort's data mirrors surges in operational activity, whereas the civilian cohort demonstrates a higher and more predictable number of tibia fractures; with reliability and numbers being important factors in training new surgeons and maintaining surgical skills. Although this study focused on specific orthopaedic trauma cases deemed essential to combat casualty care, it highlights the universal reality facing U.S. Military Medicine: as combat trauma continues to decline, military medicine as a whole will have to look elsewhere for critical trauma experience. This study confirmed military case volumes fluctuate with operational demands and evaluated one method of supplementing the declining combat trauma volumes with a local civilian trauma mission. This indicates not only the need for a system that is able to quickly adapt to the increased patient load, but also depicts how little reliability there is within the system in terms of perpetuating physician experience when the civilian trauma mission is not considered.

Outcomes of Talus Fractures Associated With High-Energy Combat Trauma.

BACKGROUND: Talus fractures are infrequent injuries that are often associated with poor clinical outcomes. Literature reviewing talus fractures is limited to a civilian population, with few studies characterizing these injuries sustained in active duty personnel. The aim of this study was to characterize talus fractures sustained in combat trauma by reporting their surgical outcomes. METHODS: The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained talus fractures in battle conditions between 2001 and 2014. These patients underwent a retrospective chart review. Injury and fracture patterns were characterized. We examined the incidence of secondary surgical procedures and reviewed patients undergoing early and late transtibial amputations. Forty-eight talus fractures were identified. RESULTS: All injuries were related to high-energy trauma: 43 (90%) resulting from improvised explosive devices (IED), 3 (6%) from gunshot wounds (GSW), and 2 (4%) from propelled explosive devices. Ten (20.8%) patients underwent early transtibial amputation. Early amputations were associated with calcaneus fractures (10/10 vs 16/38, P = .0009) but not with open fractures (8/10 vs 20/38, P = .163). Twenty-six fractures were available with longer term follow-up. Twenty-three fractures had associated injuries to the ipsilateral lower extremity. Sixteen (61.54%) injuries underwent a total of 26 additional surgical procedures. Eight fractures required secondary fusions (30.8%). Subtalar fusions were associated with ipsilateral calcaneus fractures (5/6 vs 2/10, P = .03). One patient underwent a delayed transtibial amputation 17 months after injury. CONCLUSIONS: Talus fractures sustained within the combat environment were associated with high rates of early amputations and secondary surgical intervention. When the limb was salvaged, patients could expect the need for additional procedures to address ongoing issues. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Lisfranc Injuries in an Active Duty Military Population.

BACKGROUND: Traumatic injuries to the tarsometatarsal or Lisfranc joints can be complex problems associated with long-term morbidity. Currently there is no clear consensus regarding optimal fixation methods. The purpose of this study was to evaluate the association between time from injury to treatment and treatment method with outcome. It is hypothesized that patients who underwent open reduction internal fixation (ORIF) more acutely would have higher return to duty rates. METHODS: This study is a retrospective review of 171 low-energy closed tarsometatarsal dislocations and fracture dislocations in patients identified using a Department of Defense trauma registry. Outcomes were defined as return to active duty and separation from service. Patients were categorized into cohorts by surgical treatment: ORIF, primary arthrodesis (PA), or having required a salvage arthrodesis (SA). RESULTS: The data demonstrate no significant difference between ORIF and PA as well as significantly lower return to duty rates in those who underwent SA. There was no association between increased time from injury to treatment and the observed outcomes. CONCLUSION: This study not only reinforces the importance of initial anatomic reduction and the poor outcomes of posttraumatic osteoarthritis but also suggests that SA portends poor outcomes in a highly active population. Most notably it found no significant difference in return to duty rates between ORIF and PA despite the inclusion of more "missed" and chronic injuries in the PA group. This suggests that PA may be a viable option in a young and active population regardless of treatment timing. LEVEL OF EVIDENCE: Level III, retrospective comparative series.