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

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

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Combat-Related Hemipelvectomy: 14 Cases, a Review of the Literature and Lessons Learned.

OBJECTIVES: Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques. DESIGN: Retrospective review. SETTING: Level II trauma center. PATIENTS: Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013. INTERVENTION: We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS: Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function. RESULTS: Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation. CONCLUSIONS: This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Blurred front lines: triage and initial management of blast injuries.

Recent armed conflicts and the expanded reach of international terror groups has resulted in an increased incidence of blast-related injuries in both military and civilian populations. Mass-casualty incidents may require both on-scene and in-hospital triage to maximize survival rates and conserve limited resources. Initial evaluation should focus on the identification and control of potentially life-threatening conditions, especially life-threatening hemorrhage. Early operative priorities for musculoskeletal injuries focus on the principles of damage-control orthopaedics, with early and aggressive debridement of soft-tissue wounds, vascular shunting or grafting to restore limb perfusion, and long-bone fracture stabilization via external fixation. Special considerations such as patient transport, infection control and prevention, and amputation management are also discussed. All orthopedic surgeons, regardless of practice setting, should be familiar with the basic principles of evaluation, resuscitation, and initial management of explosive blast injuries.

Translating research into practice: is evidence-based medicine being practiced in military-relevant orthopedic trauma?

Orthopedic trauma remains one of the most survivable battlefield injuries seen in modern conflicts. Translating research into practice is a critical bridge that permits surgeons to further optimize medical outcomes. Orthopedic surgeons serving in the military may treat little to no trauma in their stateside practice. In conflict zones, however, the majority of their patients will have traumatic injuries. Determining risk factors for nonevidence-based practice can help identify provider knowledge gaps, which can then be targeted before deployment. Surveys were developed which sought to identify factors contributing to continued medical education and practice, as well as scenario-based questions on military-relevant orthopedic trauma. Analysis of 188 survey respondents revealed that providers with military service and less than 10 years of practice are optimally bridging research into military-relevant orthopedic trauma practice.

Open, combat-related loss, or disruption of the knee extensor mechanism: treatment strategies, classification, and outcomes.

OBJECTIVE: To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. DESIGN: Retrospective review. SETTING: Tertiary (Level/Role V) Military Treatment Facility. PATIENTS: Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. INTERVENTION: Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. MAIN OUTCOME MEASURES: Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. RESULTS: The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. CONCLUSIONS: High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Reoperation after combat-related major lower extremity amputations.

OBJECTIVE: Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients. DESIGN: Retrospective review of a consecutive series of patients. SETTING: Tertiary Military Medical Center. PATIENTS/PARTICIPANTS: Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009. INTERVENTION: We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status. RESULTS: At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4). CONCLUSIONS: In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

Extremity War Injuries VIII: sequelae of combat injuries.

The 2013 Extremity War Injury symposium focused on the sequelae of combat-related injuries, including posttraumatic osteoarthritis, amputations, and infections. Much remains to be learned about posttraumatic arthritis, and there are few circumstances in which a definitive arthroplasty should be performed in an acutely injured and open joint. Although the last decade has seen tremendous advances in the treatment of combat upper extremity injuries, many questions remain unanswered, and continued research focusing on improving reconstruction of large segmental defects remains critical. Discussion of infection centered on the need for novel methods to reduce the bacterial load following the initial débridement procedures. Novel methods of delivering antimicrobial therapy and anti-inflammatory medications directly to the wound were discussed as well as the need for near real-time assessment of bacterial and fungal burden and further means of prevention and treatment of biofilm formation and the importance of animal models to test therapies discussed. Moderators and lecturers of focus groups noted the continuing need for improved prehospital care in the management of junctional injuries, identified optimal strategies for both surgical repair and/or reconstruction of the ligaments in multiligamentous injuries, and noted the need to mitigate bone mineral density loss following amputation and/or limb salvage as well as the necessity of developing better methods of anticipating and managing heterotopic ossification.

Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome?

BACKGROUND: Intracompartmental pressure measurements are frequently used in the diagnosis of compartment syndrome, particularly in patients with equivocal or limited physical examination findings. Little clinical work has been done to validate the clinical use of intracompartmental pressures or identify associated false-positive rates. We hypothesized that diagnosis of compartment syndrome based on one-time pressure measurements alone is associated with a high false-positive rate. METHODS: Forty-eight consecutive patients with tibial shaft fractures who were not suspected of having compartment syndrome based on physical examinations were prospectively enrolled. Pressure measurements were obtained in all four compartments at a single point in time immediately after induction of anesthesia using a pressure-monitoring device. Preoperative and intraoperative blood pressure measurements were recorded. The same standardized examination was performed by the attending surgeon preoperatively, postoperatively, and during clinical follow-up for 6 months to assess clinical evidence of acute or late compartment syndrome. RESULTS: No clinical evidence of compartment syndrome was observed postoperatively or during follow-up until 6 months after injury. Using the accepted criteria of delta P of 30 mm Hg from preoperative diastolic blood pressure, 35% of cases (n = 16; 95% confidence interval, 21.5-48.5%) met criteria for compartment syndrome. Raising the threshold to delta P of 20 mm Hg reduced the false-positive rate to 24% (n = 11; 95% confidence interval, 11.1-34.9%). Twenty-two percent (n = 10; 95% confidence interval, 9.5-32.5%) exceeded absolute pressure of 45 mm Hg. CONCLUSION: A 35% false-positive rate was found for the diagnosis of compartment syndrome in patients with tibial shaft fractures who were not thought to have compartment syndrome by using currently accepted criteria for diagnosis based solely on one-time compartment pressure measurements. Our data suggest that reliance on one-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies. LEVEL OF EVIDENCE: Diagnostic study, level II.

Heterotopic ossification resection after open periarticular combat-related elbow fractures.

A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combat-related open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion-extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries.

Use of a continuous external tissue expander in the conversion of a type IIIB fracture to a type IIIA fracture.

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

Treatment of open proximal femoral fractures sustained in combat.

BACKGROUND: Open proximal femoral fractures are rare injuries that often result from wartime high-energy causes. Limited data exist regarding the treatment and complications of these injuries. METHODS: We retrospectively reviewed the records of combat casualties treated at two institutions between March 2003 and March 2008. The casualty patient databases, medical records, radiographs, and laboratory data were reviewed to determine time to union, complication rates, and patient outcomes. RESULTS: Forty-one patients (thirty-nine men and two women) with a mean age of 25.7 years were identified as receiving treatment for open proximal femoral fractures. The mechanisms of injury for these forty-one patients were blast (twenty-nine patients [71%]), gunshot wound (eight patients [20%]), motor vehicle crash (three patients [7%]), and helicopter crash (one patient [2%]). There were thirty Type-IIIA, six Type-IIIB, and five Type-IIIC open fractures. The predominant method of definitive fixation was a cephalomedullary or reconstruction nail in thirty-four patients (83%). Thirty-nine patients had at least two years of follow-up data available for assessment of complications and radiographic union. The mean time to union was 5.1 months (range, 2.8 to 16.0 months). Complications requiring reoperation occurred in twenty-two (56%) of thirty-nine patients. Wound infection (twelve patients [31%]) and symptomatic heterotopic ossification (ten patients [26%]) were the most common complications. CONCLUSIONS: Cephalomedullary nail fixation of open Type-III wartime subtrochanteric and pertrochanteric femoral fractures can be reliably used to effect fracture union in a timely manner. The most frequent complications of treatment are wound infection and symptomatic heterotopic ossification.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma.

BACKGROUND: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. METHODS: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. RESULTS: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. CONCLUSIONS: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

Special topics.

Concerning the past decade of war, three special topics were examined at the Extremity War Injuries VII Symposium. These topics included the implementation of tourniquets and their effect on decreasing mortality and the possibility of transitioning the lessons gained to the civilian sector. In addition, the training of surgeons for war as well as residents in a wartime environment was reviewed.

Reprioritization of research for combat casualty care.

Since the beginning of the conflicts in Iraq and Afghanistan more than a decade ago, much has been learned with regard to combat casualty care. Although progress has been significant, knowledge gaps still exist. The seventh Extremity War Injuries symposium, held in January 2012, reviewed the current state of knowledge and defined knowledge gaps in acute care, reconstructive care, and rehabilitative care in order to provide policymakers information on the areas in which research funding would be the most beneficial.

Occult femoral neck fracture associated with vitamin D deficiency diagnosed by MRI: case report.

Hip fractures in the young are exceedingly rare and are usually seen in instances of high energy trauma or metabolically altered bone states. In this case report, we present an occult femoral neck fracture, diagnosed by magnetic resonance imaging, in an otherwise healthy, young, active duty male patient with an isolated vitamin D deficiency treated using cannulated percutaneous screws.

Microbiology and injury characteristics in severe open tibia fractures from combat.

BACKGROUND: Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. METHODS: We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. RESULTS: One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly associated with amputation, revision operation, and prolonged time to union. Surveillance cultures were positive in 64% of extremities and 93% of these cultures isolated gram-negative species. In contrast, infecting organisms were predominantly gram-positive. CONCLUSIONS: Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops.

Dismounted Complex Blast Injury.

The severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremity (usually involving the non-dominant side), in addition to open pelvic injuries, genitourinary, and abdominal trauma. Initial resuscitation and multidisciplinary surgical management appear to be the keys to survival. Definitive treatment follows general principals of open wound management and includes decontamination through aggressive and frequent debridement, hemorrhage control, viable tissue preservation, and appropriate timing of wound closure. These devastating injuries are associated with paradoxically favorable survival rates, but associated injuries and higher amputation levels lead to more difficult reconstructive challenges.

Dismounted complex blast injuries: patterns of injuries and resource utilization associated with the multiple extremity amputee.

The objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat between 2007 and 2010 was conducted. Data analyzed included age, injury mechanism, amputated limbs, number and type of associated injuries, blood products utilized, intensive care unit length of stay (ILOS), hospital length of stay (HLOS) and the Injury Severity Score (ISS). Patients were stratified based on the number of amputations. Sixty-three patients comprised the multiple extremity amputation (MEA) group. Ninety-eight percent sustained injuries from an improvised explosive device (IED) and 96% were dismounted. The ISS, number of surgical encounters, blood products utilized and ILOS were all clinically significantly different than controls. Care of multiple extremity amputees involves the utilization of significant resources. This knowledge may better help surgeons and administrators allocate assets at hospitals, both military and civilian, who care for this complex and challenging patient population.