Putting the ready in readiness: A post-hoc analysis of surgeon performance during a military MASCAL in Afghanistan.

BACKGROUND: All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient MASCAL event. METHODS: The sample included orthopaedic (4) and general surgeons (8) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan on 26 August 2021. One orthopaedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1. expeditionary knowledge (exam score), 2. procedural skills competencies (performance assessment score), 3. clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases were reviewed and rated (performance score) by The Joint Trauma System's Performance Improvement Branch; a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each pre-deployment measure and MASCAL surgical care. RESULTS: Pre-deployment knowledge and clinical activity measures met program benchmarks. Baseline pre-deployment procedural skills competency scores did not meet program benchmarks, however those gaps were closed through re-training, ensuring all surgeons met or exceeded the program benchmarks pre-deployment. There were very large effect sizes (Cohen's d) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. CONCLUSION: The prescribed program measures ensured all surgeons achieved pre-deployment performance benchmarks and provided high quality trauma care to our nation's servicemembers. LEVEL OF EVIDENCE: Prognostic, Level III/IV.

Measuring Competency: Improving the validity of your procedural performance assessments.

Objective: The objective of the study was to compare the use of ordinal scales and interval scales for capturing surgical competency information for general surgeons performing 3 complex trauma procedures. Background: Surgical performance assessment is typically captured using nonparametric data (eg, checklists) that do not support inferential analyses. Interval scales support parametric analyses that are essential for determining competency. We compared assessment outcomes for surgeons performing 3 complex trauma procedures using ordinal and interval scales. Methods: All participants were board-certified or eligible general surgeons. Each participant was assessed by an experienced trauma surgeon while performing 3 trauma procedures on cadavers. All assessors completed a rigorous assessment certification process. We calculated descriptive statistics to examine the differences between interval (parametric) and ordinal (nonparametric) outcomes. Results: Ordinal scales overestimated competence in up to 100% of the participants and did not identify specific performance gaps. Interval scales provided more granularity and identified specific capability gaps. Conclusions: Imprecise instrumentation conveys a false sense of competence and deprives surgeons of opportunities to close capability gaps. Measuring discrete procedural components with interval scales provides a more precise measurement of surgical competency.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Prevention of Surgical Site Infections After Major Extremity Trauma.

High-energy extremity trauma rates can be difficult to precisely state given the complexity of contributing combined mechanisms; however, the rate of open fractures in the United States is 11.5 to 13 per 100,000 people. The management of high-energy extremity fractures presents many challenges for treating surgeons, including elevated risk of surgical site infections (SSIs). In recent studies, higher risk closed injuries are associated with deep SSI rates as high as 19% after surgical treatment and for severe open injuries, which rate surpasses 30%. Fracture-related infections are associated with notable costs and decreased long-term functional outcomes. Identified risk factors for the development of deep SSIs are primarily related to the severity of injury and its location. The quality of the vast literature identifying available interventions to decrease the risk of developing SSIs is highly variable, and it is unclear how consistently these interventions are applied.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Prevention of Surgical Site Infections After Major Extremity Trauma.

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons have developed Appropriate Use Criteria for the Prevention of Surgical Site Infections (SSIs) After Major Extremity Trauma. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to determine appropriateness of various treatments for the prevention of SSIs after major extremity trauma. Scenarios were derived by identifying clinical indications typical of patients suspected of developing an SSI in clinical practice. Indications are most often parameters observable by the clinician, including symptoms or results of diagnostic tests. A total of 588 patient scenarios and 14 treatments were developed by the writing panel, a group of clinicians who are specialists in this Appropriate Use Criteria topic. Next, a separate, multidisciplinary voting panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3).

Circumventing Acute Compartment Syndrome: Outcomes from a Cadaver-based Course in Fasciotomy Procedural Skills.

Acute compartment syndrome (ACS) represents a surgical emergency requiring effective, complete fasciotomy. The purpose of this study is to evaluate cadaver-based training on the ability of practicing general surgeons to effectively perform upper extremity, thigh, and leg fasciotomies. One hundred seventeen general surgeons underwent a 2-day, cadaver-based course with formative and summative assessments based on validated scoring tools. Overall performance and critical item scores were recorded and compared utilizing analysis of variance with repeated measures and eta-squared values to evaluate effect size. For all three procedures, post-training scores were significantly improved when compared with pre-training scores (p < 0.001). Mean pre-training score for lower leg fasciotomy met the standard for competent performance of the procedure (total score > 80), whereas neither thigh nor upper extremity performance scores met this standard before training. This 2-day, cadaver-based course improves the ability of practicing general surgeons to effectively and independently perform upper extremity, thigh, and lower leg fasciotomies. (Journal of Surgical Orthopaedic Advances 32(4):238-241, 2023).

Five Influential Factors for Clinical Team Performance in Urgent, Emergency Care Contexts.

INTRODUCTION: In deployed contexts, military medical care is provided through the coordinated efforts of multiple interdisciplinary teams that work across and between a continuum of widely distributed role theaters. The forms these teams take, and functional demands, vary by roles of care, location, and mission requirements. Understanding the requirements for optimal performance of these teams to provide emergency, urgent, and trauma care for multiple patients simultaneously is critical. A team's collective ability to function is dependent on the clinical expertise (knowledge and skills), authority, experience, and affective management capabilities of the team members. Identifying the relative impacts of multiple performance factors on the accuracy of care provided by interdisciplinary clinical teams will inform targeted development requirements. MATERIALS AND METHODS: A regression study design determined the extent to which factors known to influence team performance impacted the effectiveness of small, six to eight people, interdisciplinary teams tasked with concurrently caring for multiple patients with urgent, emergency care needs. Linear regression analysis was used to distinguish which of the 11 identified predictors individually and collectively contributed to the clinical accuracy of team performance in simulated emergency care contexts. RESULTS: All data met the assumptions for regression analyses. Stepwise linear regression analysis of the 11 predictors on team performance yielded a model of five predictors accounting for 82.30% of the variance. The five predictors of team performance include (1) clinical skills, (2) team size, (3) authority profile, (4) clinical knowledge, and (5) familiarity with team members. The analysis of variance confirmed a significant linear relationship between team performance and the five predictors, F(5, 240) = 218.34, P < .001. CONCLUSIONS: The outcomes of this study demonstrate that the collective knowledge, skills, and abilities within an urgent, emergency care team must be developed to the extent that each team member is able to competently perform their role functions and that smaller teams benefit by being composed of clinical authorities who are familiar with each other. Ideally, smaller, forward-deployed military teams will be an expert team of individual experts, with the collective expertise and abilities required for their patients. This expertise and familiarity are advantageous for collective consideration of significant clinical details, potential alternatives for treatment, decision-making, and effective implementation of clinical skills during patient care. Identifying the most influential team performance factors narrows the focus of team development strategies to precisely what is needed for a team to optimally perform.

Peripheral Nerve Management in Extremity Amputations.

The effective management of peripheral nerves in amputation surgery is critical to optimizing patient outcomes. Nerve-related pain after amputation is common, maybe a source of dissatisfaction and functional impairment, and should be considered in all amputees presenting with pain and dysfunction. While traction neurectomy or transposition has long been the standard of care, both regenerative peripheral nerve interface (RPNI) and targeted muscle reinnervation (TMR) have emerged as promising techniques to improve neuroma-related and phantom pain. A multi-disciplinary and multi-modal approach is essential for the optimal management of amputees both acutely and in the delayed or chronic setting.

Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons.

INTRODUCTION: As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention. METHODS: This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d. RESULTS: Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons). CONCLUSION: There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.

Patients With Cirrhosis Who Have a Model for End-stage Liver Disease Sodium Score of 8 or Greater Are at Increased Risk of Poor Outcomes in Operatively Treated Tibia Fractures.

The purpose of this study was to compare 30-day readmission rates for cirrhotic and non-cirrhotic patients after tibia fracture fixation by retrospectively identifying all surgically managed tibial plateau, tibial shaft, and pilon fractures from 2010 through 2018 in the National Surgical Quality Improvement Program database (N=14,028). The primary outcome measure was 30-day readmission rates. Secondary outcome measures included 30-day rates of reoperation, length of stay, pulmonary embolism, deep venous thrombosis, and wound complications, including deep or superficial infection. Cirrhotic patients (n=665) and non-cirrhotic patients (n=13,363) were identified using the aspartate aminotransferase to platelet ratio index test. Cirrhotic patients were more likely to have preoperative ascites, renal failure, bleeding disorders, and preoperative transfusions. No differences were reported between the two groups in readmission rate or any of the secondary outcome measures, except that cirrhotic patients' length of stay was longer by 0.5 day. Stratification of the cirrhotic cohort demonstrated that a Model for End-stage Liver Disease sodium (MELD-Na) score of 8 or greater was associated with a 4.1-fold increase in the rate of readmission (5.9% vs 1.5%; P<.01). No other differences were identified based on MELD-Na score stratification. Patients with advanced cirrhosis (MELD-Na score ≥8) have an increased risk of 30-day readmission after tibia fracture surgery. Cirrhosis associated with a lower MELD-Na score might not significantly increase the risk of 30-day complications in patients with tibia fractures. [Orthopedics. 2022;45(2):79-85.].

Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction.

AIM: To evaluate whether a daily full-dose aspirin regimen after anterior cruciate ligament (ACL) reconstruction reduces the risk of postoperative symptomatic deep-venous thrombosis (DVT). MATERIALS AND METHODS: Single-center retrospective cohort study of patients who underwent ACL reconstruction from 2007 to 2016. One thousand two hundred thirty-three patients met inclusion criteria: 821 patients received no chemoprophylaxis and 412 patients received daily full-dose aspirin. RESULTS: A total of 10 patients, seven receiving no chemoprophylaxis and three using aspirin, sustained a postoperative symptomatic DVT. Calculated adjusted odds ratio for symptomatic postoperative DVT for aspirin versus no chemoprophylaxis was 0.928 (95% CI 0.237-3.629, P value = 0.91). Odds ratio for symptomatic postoperative DVT occurrence among tobacco users versus non-tobacco users was 3.76 (95% CI 1.077-13.124, P = 0.04). CONCLUSIONS: No statistically significant difference was observed in postoperative symptomatic DVT after ACL reconstruction in those who received full-dose aspirin chemoprophylaxis versus those with no chemoprophylaxis. Additionally, there was a significantly increased risk of postoperative symptomatic DVT with tobacco use.

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.

Injury Characteristics of Low-Energy Lisfranc Injuries Compared With High-Energy Injuries.

BACKGROUND: Lisfranc injuries result from high- and low-energy mechanisms though the literature has been more focused on high-energy mechanisms. A comparison of high-energy (HE) and low-energy (LE) injury patterns is lacking. The objective of this study was to report injury patterns in LE Lisfranc joint injuries and compare them to HE injury patterns. METHODS: Operative Lisfranc injuries were identified over a 5-year period. Patient demographics, mechanism of injury, injury pattern, associated injuries, missed diagnoses, clinical course, and imaging studies were reviewed and compared. HE mechanism was defined as motor vehicle crash, motorcycle crash, direct crush, and fall from greater than 4 feet and LE mechanism as athletic activity, ground level twisting, or fall from less than 4 feet. Thirty-two HE and 48 LE cases were identified with 19.3 months of average follow-up. RESULTS: There were no differences in demographics or missed diagnosis frequency (21% HE vs 18% LE). Time to seek care was not significantly different. HE injuries were more likely to have concomitant nonfoot fractures (37% vs 6%), concomitant foot fractures (78% vs 4%), cuboid fractures (31% vs 6%), metatarsal base fractures (84% vs 29%), displaced intra-articular fractures (59% vs 4%), and involvement of all 5 rays (23% vs 6%). LE injuries were more commonly ligamentous (68% vs 16%), with fewer rays involved (2.7 vs 4.1). CONCLUSIONS: LE mechanisms were a more common cause of Lisfranc joint injury in this cohort. These mechanisms generally resulted in an isolated, primarily ligamentous injury sparing the lateral column. Both types had high rates of missed injury that could result in delayed treatment. Differences in injury patterns could help direct future research to optimize treatment algorithms. LEVEL OF EVIDENCE: Level III, comparative series.

Primary Arthrodesis versus Open Reduction and Internal Fixation for Low-Energy Lisfranc Injuries in a Young Athletic Population.

BACKGROUND: There are 2 Level I studies comparing open reduction and internal fixation (ORIF) and primary arthrodesis (PA) in high-energy Lisfranc injuries. There are no studies comparing ORIF and PA in young athletic patients with low-energy injuries. METHODS: All operatively managed low-energy Lisfranc injuries sustained by active duty military personnel at a single institution were identified from 2010 to 2015. The injury pattern, method of treatment, and complications were reviewed. Implant removal rates, fitness test scores, return to military duty rates, and Foot and Ankle Ability Measure (FAAM) scores were compared. Thirty-two patients were identified with the average age of 28 years. PA was performed in 14 patients with ORIF in 18. RESULTS: The PA group returned to full duty at an average of 4.5 months whereas the ORIF group returned at an average of 6.7 months ( P = .0066). The PA group ran their fitness test an average of 9 seconds per mile slower than their preoperative average whereas the ORIF group ran it an average of 39 seconds slower per mile ( P = .032). There were no differences between the 2 groups in the FAAM scores at an average of 35 months. Implant removal was performed in 15 (83%) in the ORIF group and 2 (14%) in the PA group ( P = .005). CONCLUSIONS: Low-energy Lisfranc injuries treated with primary arthrodesis had a lower implant removal rate, an earlier return to full military activity, and better fitness test scores after 1 year, but there was no difference in FAAM scores after 3 years. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Tips and tricks for ORIF of displaced femoral neck fractures in the young adult patient.

Femoral neck fractures in the young adult are a less common, but potentially functionally significant injury commonly occurring after high-energy trauma. The management goals of these injuries are the maintenance of a native hip joint absent avascular necrosis and nonunion. The primary determinant to this end is an anatomic reduction in displaced fractures with stable fixation. In this paper, the authors provide a set of technical tips and tricks to aid orthopedic surgeons in the surgical management of these injuries while reviewing the most recent literature available to inform clinical decision making. The paper includes the recommendations of the authors from the Denver Health Orthopaedic Trauma Service.

Operative and Nonoperative Management of Achilles Tendon Ruptures in Active Duty Military Population.

BACKGROUND: The optimal management of Achilles tendon ruptures continues to be a subject of debate in orthopedics. These injuries are common in the active duty military population. The purpose of this study was to retrospectively compare the results of operative and nonoperative management of Achilles tendon ruptures in the active duty military population following the publication of a landmark level I study that has influenced practice patterns. METHODS: All Achilles tendon injuries in active duty patients were identified at a single military institution from January 1, 2011, to January 1, 2014. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded along with return to duty status, deep vein thrombosis (DVT), rerupture, and other complication data. Rates of DVT, rerupture, other complications, and return to duty (including time to return) were then compared. Demographic data were described. Fifty-seven male patients met inclusion criteria with an average age of 31 years. There were 27 in the operative group and 30 in the nonoperative group. There were no significant differences in group demographics. RESULTS: There were no DVTs in either treatment group. There were no wound complications in the operative group. There were no significant differences in the rates of rerupture, return to duty, or other complications. There were 2 reruptures in the nonoperative group. Both were treated nonoperatively. There was one rerupture in the operative group that was treated nonoperatively. All reruptures were partial tears. Two patients underwent repair with flexor hallucis longus augmentation. Both of these patients were initially managed nonoperatively. When available data on time to return to duty was analyzed, patients who underwent operative management returned to duty on average approximately one and a half months earlier (6.7 vs 8.2 months) than nonoperative patients (P = .04). In 2011, 12% of injuries were treated nonoperatively; in 2012, 57%; and in 2013, 84%. CONCLUSIONS: Similar to previously published work, this retrospective analysis found no significant difference in complication, DVT, or rerupture rates. The rate of rerupture in this study was slightly higher than previously published work in the era of functional rehabilitation, but the sample size was small. The data were limited with respect to functional outcome for comparison; however, the rate of return to active duty was not significantly different. The data also demonstrate a shift in institutional treatment pattern for Achilles injuries in this population over the 3-year study period. Operatively treated patients did have a statistically significant reduction in the time required to return to active duty of approximately one and a half months, which may represent a clinically significant difference in highly active workers or highly active people. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Anthropometry of the Human Scaphoid Waist by Three-Dimensional Computed Tomography.

Published measurements for the scaphoid are scarce. The purpose of this study is to define anthropometric norms for the waist of the scaphoid to assist in optimizing bone graft quantity and implant use. Computed tomography images of the wrist were reviewed by three surgeons. Anthropometric data were gathered, including the scaphoid waist diameter in two dimensions and the scaphoid waist volume. Each study was measured twice, allowing for determination of inter- and intraobserver reliability. Forty-three studies were examined (23 female and 20 male). Average measurements of the scaphoid waist were 11.28 ± 0.26 mm in the sagittal plane and 8.70 ± 0.17 mm in the coronal plane, and the waist volume was 715 ± 33.0 mm3. Specific measures of the narrowest portion of the scaphoid are provided by this study. Measurements of the scaphoid waist through the use of three-dimensional imaging are an accurate method with good inter- and intraobserver reliability. The measurements obtained from this study can be applied to guide graft and implant selection for treatment of scaphoid waist fractures and nonunions.

Targeted Muscle Reinnervation of the Brachium: An Anatomic Study of Musculocutaneous and Radial Nerve Motor Points Relative to Proximal Landmarks.

PURPOSE: Targeted muscle reinnervation (TMR) offers enhanced prosthetic use by harnessing additional neural control from unused nerves in the amputated limb. The purpose of this study was to document the location and number of motor end plates to each muscle commonly used in TMR in the brachium relative to proximally based bony landmarks. METHODS: We dissected 18 matched upper limbs (9 fresh-frozen cadavers). The locations of each of the nerves' muscular insertions into the medial biceps and brachialis were measured relative to the anterolateral tip of the acromion. The terminal branches to the lateral triceps were measured relative to the posterolateral tip of the acromion. Both the number of branches and the location of the muscular insertions were documented. Common descriptive statistics were used to describe the data. RESULTS: There was a median of 2 branches to the medial biceps located 19.6 cm from the anterolateral tip of the acromion (range, 15-25 cm). There was a median of 3.5 branches to the brachialis located 24.2 cm from the anterolateral tip of the acromion (range, 19-27.5 cm). There was a median of 2.5 branches to the lateral triceps located 21.6 cm from the posterolateral tip of the acromion (range, 11-29 cm). The mean distances to the primary branch muscle and the number of smaller branches were not significantly different when compared by sex or side. CONCLUSIONS: Motor points for the medial biceps, brachialis, and lateral triceps can be identified reliably using proximal landmarks in targeted muscle reinnervation. CLINICAL RELEVANCE: The data obtained from this study may assist the surgeon in localizing the nerve branches and muscular insertions for the commonly used muscles for TMR of the brachium.

Predictors of inpatient and outpatient healthcare utilization in veterans with traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) can place a significant financial and resource burden on healthcare systems. This study examined predictors of outpatient and inpatient healthcare utilization in veterans with a history of TBI. METHODS: A secondary analysis was conducted on data from 1565 veterans with TBI and 1565 veterans without TBI seen for healthcare services at the VA Palo Alto Health Care System between 2000 and 2010. Patterns and predictors of outpatient and inpatient medical and psychiatric care were examined. RESULTS: Veterans with TBI utilized significantly more services compared with the control group. The TBI group was seen for more than 160 000 outpatient services and was almost 9 times more likely to be hospitalized than the control group. Although psychiatric disorders were more prevalent in the TBI group and associated with increased medical and mental health utilization within the TBI group, they did not account fully for the significant group differences. CONCLUSIONS: Veterans with a history of TBI have much greater healthcare needs than veterans without TBI, likely because of non-TBI-related factors. Increased monitoring and early intervention treatments may be warranted for certain at-risk veterans with the goal of minimizing their need for long-term or extensive healthcare services in the future.