Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures.

PURPOSE: Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT. METHODS: A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT. RESULTS: Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71). CONCLUSIONS: The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Prevalence of Amyloid Deposition in Patients Undergoing Surgical Repair of Traumatic Distal Biceps Tendon Ruptures.

Purpose: As many as one-third of patients with heart failure secondary to systemic, wild-type transthyretin amyloidosis have an associated distal biceps tendon (DBT) rupture. Our purpose was to identify the prevalence of amyloid deposition in patients undergoing operative repair of acute traumatic DBT ruptures. Methods: In this prospective investigation, a consecutive series of patients who underwent repair of an acute traumatic DBT rupture underwent a tendon biopsy to assess for amyloid deposition. All specimens were viewed under gross microscopy by a board-certified pathologist. For initial screening, either Congo red or Thioflavin-T immunohistochemistry analysis was conducted to determine amyloid status. If staining was positive for amyloid deposition using either technique, the tissue sample was sent to an outside facility for specific amyloid protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were also recorded for each patient. Results: A total of 30 patients who underwent biopsy and repair of an acute DBT rupture were included. The mean age was 48 years, and all patients were men. Seven (23%) patients had a history of carpal tunnel syndrome, and 1 (3%) patient had evidence of heart failure at the time of surgery. One (3%) patient had evidence of amyloid deposition in the DBT, which was confirmed using liquid chromatography-tandem mass spectrometry. Conclusions: Although one-third of patients with heart failure secondary to cardiac amyloidosis have an associated DBT rupture, younger patients with acute traumatic DBT ruptures do not appear to be uniquely at risk for amyloid deposition at the time of DBT repair. Larger registry studies may be necessary to define the risk of developing cardiac amyloidosis years after sustaining an acute DBT rupture. Type of study/level of evidence: Prognostic IV.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

BACKGROUND: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. PURPOSE: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. RESULTS: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. CONCLUSION: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

Low Risk of Recurrence After Posterior Labral Repair of the Shoulder in a High-Risk United States Military Population.

PURPOSE: To examine the results of isolated arthroscopic posterior labral repair of the shoulder in an active military population, looking specifically at the reoperation rate and rate of return to previous military activity with a minimum follow-up period of 2 years. METHODS: A retrospective case series was performed in active-duty military service members who underwent isolated, primary arthroscopic posterior labral repair at a single academic military treatment facility between 2009 and 2015 and had at least 2 years of follow-up. Patients were excluded if they were of non-active-duty status, had insufficient follow-up (<2 years), or had undergone a concurrent procedure. Injury presentation, demographic data, and surgical data (i.e., surgical positioning, number of anchors, and anchor placement location) were compiled manually. Outcomes including the rate of return to active duty, recurrence of symptoms, and need for revision surgery were evaluated. RESULTS: Sixty-five patients were included. After arthroscopic repair, a high rate of return to previous military duties (83%) was noted at short- to mid-term follow-up (mean ± standard deviation, 3.04 ± 1.30 years), with 1 patient (1.5%) requiring revision arthroscopic repair and 10 patients (15.5%) showing activity-limiting shoulder pain preventing a return to active duty. Intraoperative positioning (P = .17), a low anchor position (P = .27), and the number of anchors used (P = .62) were not found to be significant contributors to continued postoperative pain or recurrent instability. CONCLUSIONS: Arthroscopic intervention resulted in a reliable rate of glenohumeral stability with a low rate of surgical revision and a high rate of return to military duty at short- to mid-term follow-up. However, 1 in 6 military service members showed significant, activity-limiting shoulder pain postoperatively that did not permit a return to previous military activities after surgical intervention. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Orthopaedic Residency Training Structure: Implications on Quantity and Quality of Scholarship.

The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175-179, 2019).

Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology.

BACKGROUND: There is a paucity of literature describing distal femoral osteotomies (DFO) in regards to complications and outcomes with previously studied cohorts containing primarily older, arthritic subjects. There has been no study to date focusing on younger, pre-arthritic patients. METHODS: All service members indicated for distal femoral osteotomy for coronal plane malalignment were isolated from military treatment centers between 2007 and 2013. Demographic and surgical variables were extracted, and perioperative complications, clinical course, and return to military function were extracted using clinical notes and radiographs. RESULTS: A total of 22 knees in 19 patients were identified at an average 3.2 year follow-up, with the exclusion of 16 individuals. Statistical analysis revealed worse outcomes associated with smoking, over correction, breach of the medial cortex, and prior surgeries. Overall 58% of patients left the military as the result of knee dysfunction despite an average improvement in visual analog scores (VAS) from 4.0 to 1.9 (p = 0.004). CONCLUSIONS: While offloading the lateral compartment improves symptoms at short to midterm follow-up preventing progression to arthroplasty, young active duty military members have suboptimal return to duty rates.

Orthopaedic and Plastic Surgery Training Differences Manifested in the Analysis of Distal Radius Fracture Fixation.

All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedic surgeons. While there were no significant differences in baseline demographics between the patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFs fixed by orthopaedic surgeons. While there was a significant difference for extra-articular fractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53-57, 2019).

Effect of Anterior Anchor on Clinical Outcomes of Type II SLAP Repairs in an Active Population.

This study evaluated the role of anchor position in persistence of pain and/or revision biceps tenodesis after arthroscopic repair of type II superior labrum anterior and posterior (SLAP) lesions and assessed for patient- and injury-specific variables influencing clinical outcomes. Active-duty service members who underwent arthroscopic repair of type II SLAP lesions between March 1, 2007, and January 23, 2012, were identified. Patients with less than 2-year clinical follow-up; type I, III, and IV SLAP lesions; and primary treatment with biceps tenodesis and/or rotator cuff repair at the time of index surgery were excluded. Demographic, preoperative, and operative variables, including anchor positions, were reviewed and evaluated for association with outcomes. Total failure rate (defined as either surgical and/or clinical failure), anchor position, and return to military function were the primary outcomes of interest. Forty-nine patients underwent type II SLAP repairs with a mean follow-up of 52.3 months. Forty-eight (97.9%) were men, and mean age was 35.2 years. Eleven patients (22%) underwent subsequent subpectoral biceps tenodesis. Forty patients (82%) returned to military function, whereas 9 patients (18%) had medical discharge for significant, rate-limiting, shoulder pain. Age was a significant predictor of surgical failure. Patients with anchor position anterior to the biceps attachment had no increased risk of clinical or surgical failure compared with patients with only posterior-based anchors. Anchor placement anterior to the biceps tendon was not associated with inferior outcomes. Younger age was shown to be a poor prognostic factor in patients' ability to return to active duty. Revision with biceps tenodesis showed significant utility in achieving good clinical outcomes and return to duty in more than 90% of patients. Patient-, injury-, and surgery-specific variables need to be identified as prognostic indicators so that clinical outcomes can continue to be improved. [Orthopedics. 2019; 42(1):e32-e38.].

Autologous Chondrocyte Implantation and Tibial Tubercle Osteotomy for Patellofemoral Chondral Defects: Improved Pain Relief and Occupational Outcomes Among US Army Servicemembers.

BACKGROUND: The occupational and functional results of patellofemoral autologous chondrocyte implantation (ACI) are underreported. This investigation sought to establish clinical outcomes and rates for return to work in a predominantly high-demand military cohort undergoing this procedure. PURPOSE: To determine the return-to-work, pain relief, and perioperative complication rates in a high-demand athletic cohort undergoing patellofemoral ACI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All military servicemembers from 2 military medical centers undergoing ACI for high-grade patellofemoral chondral defects between 2006 and 2014 were identified, and data were abstracted from their medical records and clinical databases. Demographic and surgical variables were obtained for patients with at least 2 years of postoperative follow-up, and perioperative complications, rates of return to work, and survivorship from revision were quantified. RESULTS: Seventy-two patients (72%) had >2-year follow-up and had patellofemoral ACI for high-grade chondral defects, with 66 knees (91%) undergoing a concomitant offloading tibial tubercle osteotomy. Mean follow-up was 4.3 years (range, 2.0-9.9 years). The mean ± SD age was 34.4 ± 6.1 years; 86% were male; and 57% were involved in military occupational specialties of heavy or very heavy demand. Second-generation patellofemoral ACI with a type I/III collagen membrane was used for 85% of knees. Most defects were isolated to the patella (n = 40, 55%). The mean total defect surface area was 4.5 ± 2.9 cm2 (range, 2.7-13.5 cm2). Fifty-six servicemembers (78%) returned to their occupational specialties. Three patients (4.1%) were classified as having surgical failures, requiring subsequent knee arthroplasty (n = 2) or a revision chondral procedure (n = 1). Mean visual analog scores improved significantly from 6.5 ± 1.5 to 3.2 ± 2.1 ( P < .0001). Multivariate analysis identified use of a periosteal patch as the only significant independent predictor for surgical ( P = .013) and overall ( P = .033) failures. Age <30 years ( P = .019), female sex ( P = .019), and regular tobacco use ( P = .011) were independent predictors of overall failure. CONCLUSION: For patellofemoral chondral defects without a failed primary procedure, second-generation ACI successfully returned to work 78% of patients of moderate to very heavy occupational demand with significantly decreased patient-reported knee pain. Risk factors after ACI for patellofemoral articular lesions for overall failure were age <30 years, female sex, and tobacco use, while surgical and overall failures were associated with periosteal patch use.

Effect of Ankle Position on Tibiotalar Motion With Screw Fixation of the Distal Tibiofibular Syndesmosis in a Fracture Model.

BACKGROUND: Anatomic reduction and fixation of the syndesmosis in traumatic injuries is paramount in restoring function of the tibiotalar joint. While overcompression is a potential error, recent work has called into question whether ankle position during fixation really matters in this regard. Our study aimed to corroborate more recent findings using a fracture model that, to our knowledge, has not been previously tested. METHODS: Twenty cadaver leg specimens were obtained and prepared. Each was tested for tibiotalar motion under various conditions: intact syndesmosis, intact syndesmosis with lag screw compression, pronation external rotation type 4 (PER-4) ankle fracture with syndesmotic disruption, and single-screw syndesmotic fixation followed by plate and screw fracture and syndesmotic screw fixation. In each situation, the ankle was held in alternating plantarflexion and dorsiflexion when inserting the syndesmotic screw with the subsequent amount of maximal dorsiflexion being recorded following hand-tight lag screw fixation. RESULTS: While ankle range of motion increased significantly with creation of the PER-4 injury, under no condition was there a statistically significant change in maximal dorsiflexion angle. CONCLUSION: Ankle position during distal tibiofibular syndesmosis fixation did not limit dorsiflexion of the ankle joint. CLINICAL RELEVANCE: Our findings suggest that maximal dorsiflexion during syndesmotic screw fixation may not be necessary.

Outcomes Following Carpal Tunnel Release in Patients Receiving Workers' Compensation: A Systematic Review.

BACKGROUND: Carpal tunnel syndrome (CTS) is a common occupational pathology, representing a high percentage of workers' compensation (WC) claims. METHODS: The literature was reviewed for all studies evaluating CTS outcomes including WC patients between 1993 and 2016. A total of 348 articles were identified; 25 of which met inclusion and exclusion criteria. A systematic review was generated; patient demographics, outcomes, and complications were recorded. Weighted averages were calculated for the demographic and outcome data. Categorical data such as complications were pooled from the studies and used to determine the overall complication rate. Statistical significance was determined between WC and non-WC cohorts when applicable with the chi-square statistic. RESULTS: The WC cohort included 1586 wrists, and the non-WC cohort included 2781 wrists. The WC cohort was younger and more often involved the dominant extremity. The WC cohort was less likely to have appropriate physical exam findings confirming diagnosis and electrodiagnostic studies. WC patients took almost 5 weeks longer to return to work, were 16% less likely to return to preinjury vocation, and had lower Standard Form (SF)-36 scores. Finally, WC patients had nearly 3 times the number of complications and nearly twice the rate of persistent pain. CONCLUSIONS: WC patients undergoing carpal tunnel release (CTR) fare poorly as compared with non-WC patients in nearly every metric. Higher rates of postoperative pain with delayed return to work can be anticipated in a WC cohort. In addition, WC patients receive suboptimal preoperative workup, and it is possible that unnecessary surgery is being completed in these cases. These findings are important to consider when treating the WC patient with CTS.

Current Evidence Regarding Routine Antibiotic Prophylaxis in Hand Surgery.

Background: Although routine antibiotic prophylaxis immediately preceding an orthopedic surgery has become the standard of care in most cases, this practice is poorly defined in hand surgery. The purpose of this analysis is to review the most current literature of antibiotic use in hand surgery. Methods: A careful review of the literature regarding routine antibiotic prophylaxis in hand surgery was made. Current relevant resources were used in the construction of this review. Results: There is a mixed consensus on the role for prophylactic antibiotics in hand surgery with some resources and data showing support and others opposed. Conclusions: Based on the current literature, the authors recommend the following patient characteristics not receive antibiotics: clean hygienic patients, without autoimmune disease, and those not taking steroid medication. Surgical characteristics that would render prophylaxis unnecessary include those without hardware, those without reasonable risk of hematoma formation, or those performed at an ambulatory surgery center as opposed to a large hospital. However, the decision should be made on a case-by-case basis weighing the evidence presented.

Publication Rate and Impact Factor for Society of Military Orthopedic Surgeons. Annual Meeting Presentations, 2009-2013.

INTRODUCTION: The Society of Military Orthopaedic Surgeons (SOMOS) is a robust academic organization with more than 1,000 members and has held annual academic scientific meetings since 1958. Currently, there is a paucity of data regarding the volume and quality of orthopaedic surgery presentations accepted for peer-reviewed publication. The purpose of this study was to answer the following questions: (1) What is the publication acceptance rate for abstract presented at SOMOS meetings? (2) What is the distribution by orthopaedic subspecialty for SOMOS presentations accepted for publication? (3) What is the overall quality of these publications? MATERIALS AND METHODS: Abstracts of podium presentations at SOMOS were reviewed from 2009 to 2013. Author institutional information was obtained. Abstracts were then queried in PubMed to obtain publication status, time to publication, and impact factor of the journal in which the manuscript was successfully published. RESULTS: From 2009 to 2013, 592 abstracts were presented at the SOMOS conference. Overall, 59% of abstracts went on to publication at a mean of 18.1 months. Published manuscripts appeared in 59 journals with a mean impact factor of 2.6. The subspecialties of spine (67%) and basic science (66%) achieved the highest abstract publication rate while sports had the highest mean impact factor (3.3). CONCLUSIONS: The annual SOMOS meeting is a productive academic event, producing quality presentations resulting in a high manuscript publication rate in every orthopaedic surgery subspecialty. This is the first series to demonstrate overall productivity of a general orthopaedic surgery scientific meeting as well as the subspecialty-specific impact factors of published investigations.

Return to Preoperative Function After Autologous Cartilage Implantation of the Knee in Active Military Servicemembers.

BACKGROUND: Autologous chondrocyte implantation (ACI) has been shown to provide adequate durability, pain relief, and improved long-term functional outcomes in the average patient, but proof of its efficacy in individuals with greater than average physical demands is scarce. Further knowledge is required to understand which patients may benefit from ACI and to identify which risk factors are associated with failure to return to the preinjury activity level. PURPOSE: To determine the occupational outcomes, rates of reoperation, and variables predictive of suboptimal outcomes after ACI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All active-duty military servicemembers in the United States who underwent ACI of the knee between 2004 and 2014 were identified. Demographic information, injury characteristics, surgical variables, and clinical and surgical outcomes were extracted from the medical record. Univariate and multivariate analyses were used to determine significant independent predictors of clinical and surgical failures. RESULTS: A total of 90 patients (91 knees) met the inclusion criteria. The cohort was predominantly male (86%), with a mean age of 34.5 ± 6.3 years (range, 20-50 years). The most common location of the articular cartilage lesion was the patellofemoral compartment (54 lesions, 59%), and the mean Outerbridge grade and size were 3.8 ± 0.4 and 4.00 ± 2.77 cm2 (range, 1.2-15.0 cm2), respectively. A total of 72 patients (79%) had at least 1 previous knee procedure. Nearly three-quarters of patients (71%) underwent concomitant procedures. At a mean follow-up of 59.9 ± 27.1 months (range, 24.0-140.1 months), 60% of our patients reported significant improvement in knee pain and did not require further surgical intervention. Multivariate analysis identified age <30 years as the only significant independent predictor of both clinical (P = .011) and overall failure (P = .014). Moderate-demand military occupational specialties (P = .036), exclusive involvement of the patellofemoral compartment (P = .045), and use of a periosteal patch (P = .0173) were additionally found to be independent predictors of surgical failure. CONCLUSION: Treatment of articular cartilage defects of the knee with ACI in physically active young individuals can return nearly two-thirds of individuals to daily activity with decreased pain and improved function. Risk factors for failure after ACI surgery were age younger than 30 years, lower demand occupation, exclusive involvement of the patellofemoral compartment, prior microfracture, and use of a periosteal patch.

The Success of Hip Arthroscopy in an Active Duty Population.

PURPOSE: To examine the outcomes of arthroscopic treatment of the hip in a young, active military population. Specifically, the ability to return to duty was the prime indicator of success. In addition, an objective evaluation of various demographic and surgery-related variables was performed to identify predictors for success or failure of treatment in this military population. METHODS: A retrospective chart review was undertaken to ascertain the results of hip arthroscopy at a single academic military medical center. A total of 206 patients underwent 223 hip arthroscopies during a 13-year period (2000-2013). Of these, 159 patients met the inclusion criteria, which included active duty military service and at least 12-month follow-up. Veterans Affairs Beneficiaries, active duty dependents, and those with less than 12 months of follow-up were excluded. Surgeries were performed by 1 of 5 fellowship-trained orthopaedic surgeons. Data were collected from the Armed Forces Health Longitudinal Technology Application, Electronic profiling system, and Physical Evaluation Board. RESULTS: A total of 159 patients were available for the study, 102 males and 57 females. The average age of the patients overall was 30.9 ± 8.3 years (range, 18-52 years). Junior enlisted, which is considered entry level, made up 64.2% of the subjects. The most common diagnosis was femoroacetabular impingement, and the most common procedure performed was acetabuloplasty. Twenty-two percent of patients underwent evaluation by the medical retention board after hip arthroscopy and were separated from military service. Seventy-eight percent of soldiers were maintained on active duty after hip arthroscopy. The overall complication rate was 15.7%, with a major complication rate of 1.25% defined as femoral neck fracture, abdominal compartment syndrome, osteonecrosis, deep vein thrombosis and/or pulmonary embolus, and septic arthritis. Univariate analysis of risk factors showed the presence of a complication to be a significant predictor for failure to return to active duty (odds ratio [OR] 4.04, P = .0035) as was senior noncommissioned officer rank (OR 0.20, P = .0347). Multivariate analysis showed only the presence of a complication to be a significant predictor for failure to return to active duty (OR 3.71, P = .0083). CONCLUSIONS: Hip arthroscopy in a military population is effective in treating multiple causes and retaining soldiers on active duty status. Complications of any kind from surgery or postoperatively are significant predictors of medical separation and may warrant earlier initiation of a medical evaluation board. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Characterization of Metacarpal Fractures in a Military Population.

The purpose of this study was to investigate the incidence and type of metacarpal (MC) fractures in a military population, and whether these fractures are related to age, military occupational specialty, aggression, or accidental injury. A retrospective record-based review was conducted at a single military center over a 5-year period. Service members with index finger through small finger MC fracture were identified. Data were collected utilizing Armed Forces Health Longitudinal Technology Application and electronic profile (e-profile) databases. Data collected included demographic information, mechanism of injury, nature of injury, total number of visits, and estimated time on physical restriction. 400 patients met inclusion criteria. Males accounted for 94% of the study population, 75% of fractures were of the small finger MC, 54% of patients were between 20 and 24 years, 90% were sustained by junior enlisted personnel, and most occurred by punching. Men aged <25 years were more likely to have intentional injuries. Total time on limited duty profile averaged 38 days and the average medically nondeployable profile was 26 days. MC fractures most commonly affect young, male, junior enlisted service members and are often self-inflicted. As a result, these injuries account for time lost at work, reduced job performance, and decreased medical readiness.

Medialized Clavicular Bone Tunnel Position Predicts Failure After Anatomic Coracoclavicular Ligament Reconstruction in Young, Active Male Patients.

BACKGROUND: Recent radiographic data have suggested that medialized conoid tunnel placement greater than 25% of absolute clavicular length is correlated with early failure after anatomic coracoclavicular ligament reconstructions. A comparison with a larger active duty military cohort of clinical and radiographic outcomes can serve as a basis for standardizing surgical technique. PURPOSE: To establish the ideal radiographic tunnel position for anatomic coracoclavicular ligament reconstruction and to elucidate variables associated with early loss of reduction and ability to return to active-duty military service. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the military's electronic medical record between the years 2000 and 2013 was performed. All anatomic coracoclavicular reconstructions at a single institution were included for analysis, and nonanatomic or revision reconstructions were excluded. Radiographic failure was defined as 6 mm of superior clavicle displacement on immediate postoperative films. RESULTS: A cohort of 38 patients underwent 39 anatomic coracoclavicular reconstructions. Average follow-up time was 26 months (range, 1.2-92 months). A total of 20 radiographic failures were identified, with an average conoid tunnel ratio of 0.27. When conoid tunnel ratios were compared with a reference ratio of 0.20 to 0.25, increased risk of failure was statistically significant with lateralization greater than 0.20 (P = .018; odds ratio [OR] = 40 [95% CI, 1.05-999.06]) or with medialization of 0.251 to 0.30 (P = .002; OR = 39 [95% CI, 1.58-944.36]) or greater than 0.30 (P = .029; OR = 21 [95% CI, 0.77-562.15]). Medialization of the trapezoid position greater than 0.16 (vs a range of 0.13-0.16) was also found to be significant for failure (P < .023; OR = 8 [95% CI, 1.33-48.18]). However, these significant findings did not correlate with symptoms or ability to return to duty (P > .05). CONCLUSION: The optimal technique for treating acromioclavicular separations has yet to be determined. Recently, anatomic coracoclavicular reconstruction has demonstrated biomechanical superiority to previously described methods. The findings of optimal tunnel positioning in anatomic reconstructions from this large active-duty military cohort can assist preoperative planning to reduce failure rates when treating these difficult injuries.