Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Pipeline to Military Orthopaedic Leadership: 20 Years of Race and Gender Diversity Trends Within Military Orthopaedic Surgery Fellowship Training.

Background: The lack of trainees from underrepresented race and gender backgrounds in orthopaedic surgery fellowship training has been well reported in the literature. The purpose of this study was to investigate the demographic trends of federally sponsored military orthopaedic surgery fellows in the Army, Navy, and Air Force. We hypothesize that there has been an increase in women selected for fellowship but that there has been no change in the race demographics of military fellows over the past 2 decades. Methods: A retrospective review of all available demographic data collected by the Army, Air Force, and Navy since the beginning of tracking federally funded fellowship training in orthopaedic surgery was completed (1998-2021). Data were grouped into 4-year periods for analysis to closely mirror the military assignment cycle. Results: Three hundred sixty-two military orthopaedic surgery fellowship board selectees were included in our analysis. The proportion of women fellows increased from 3% (n = 2/69) over 2001 to 2004 to 21% (n = 17/82) during 2017 to 2020 (p < 0.05). Fellows who identified as White comprised 82% (n = 297) of the cohort during the study period. Individuals who identified as Asian were the next highest proportion of fellows at 4% (n = 16), followed by Black (n = 14, 4%) and Hispanic (n = 13, 3%). Individuals who identified as Native Hawaiian/Pacific Islander represented 1% (n = 3), and an additional 6% (n = 20) fellows identified as "other" or "undeclared." Over the 20-year study period, representation of Asian, Black, Native Hawaiian, and Hispanic fellows did not increase (p = 0.79, 0.81, 0.45, 0.34, respectively). Conclusions: Within military orthopaedics, there has been increased representation of women in fellowship training over the past 20 years. However, the proportion of fellows from underrepresented racial and ethnic groups has remained stagnant. One barrier to improving gender and race representation is the currently imprecise and inconsistent collection of demographic information. Importantly, fellowship training has a direct effect on future leadership opportunities within the military orthopaedic surgery community. A more diverse leadership may help to inspire future generations of military orthopaedic surgeons. Level of Evidence: IV.

Health-Care Utilization and Expenditures Associated with Long-Term Treatment After Combat and Non-Combat-Related Orthopaedic Trauma.

BACKGROUND: The long-term consequences of musculoskeletal trauma can be profound and can extend beyond the post-injury period. The surveillance of long-term expenditures among individuals who sustain orthopaedic trauma has been limited in prior work. We sought to compare the health-care requirements of active-duty individuals who sustained orthopaedic injuries in combat and non-combat (United States) environments using TRICARE claims data. METHODS: We identified service members who sustained combat or non-combat musculoskeletal injuries between 2007 and 2011. Combat-injured personnel were matched to those in the non-combat-injured cohort on a 1:1 basis using biologic sex, year of the injury, Injury Severity Score (ISS), and age at the index hospitalization. Health-care utilization was surveyed through 2018. The total health-care expenditures over the post-injury period were the primary outcome. These were assessed as a total overall cost and then as costs adjusted per year of follow-up. We used negative binomial regression to identify the independent association between risk factors and health-care expenditures. RESULTS: We identified 2,119 individuals who sustained combat-related orthopaedic trauma and 2,119 individuals who sustained non-combat injuries. The most common mechanism of injury within the combat-injured cohort was blast-related trauma (59%), and 418 individuals (20%) sustained an amputation. The total costs were $156,886 for the combat-injured group compared with $55,873 for the non-combat-injured group (p < 0.001). Combat-related orthopaedic injuries were associated with a 43% increase in health-care expenditures (incidence rate ratio, 1.43 [95% confidence interval, 1.19 to 1.73]). Severe ISS at presentation, ≥2 comorbidities, and amputations were also significantly associated with health-care utilization, as was junior enlisted rank, our proxy for socioeconomic status. CONCLUSIONS: Health-care requirements and associated costs are substantial among service members sustaining combat and non-combat orthopaedic trauma. Given the sociodemographic characteristics of our cohort, we believe that these results are translatable to civilians who sustain similar types of musculoskeletal trauma.

A Natural History of Patients Treated Operatively and Nonoperatively for Spinal Metastases Over 2 Years Following Treatment: Survival and Functional Outcomes.

STUDY DESIGN: Prospective observational study. OBJECTIVE: We present the natural history, including survival and function, among participants in the prospective observational study of spinal metastases treatment investigation. SUMMARY OF BACKGROUND DATA: Surgical treatment has been touted as a means to preserve functional independence, quality of life, and survival. Nearly all prior investigations have been limited by retrospective design and relatively short-periods of post-treatment surveillance. METHODS: This natural history study was conducted using the records of patients who were enrolled in the prospective observational study of spinal metastases treatment study (2017-2019). Eligible participants were 18 or older and presenting for treatment of spinal metastatic disease. Patients were followed at predetermined intervals (1, 3, 6, 12, and 24-mo) following treatment. We conducted cox proportional hazard regression analysis adjusting for confounders including age, biologic sex, number of comorbidities, type of metastatic lesion, neurologic symptoms at presentation, number of metastases involving the vertebral body, vertebral body collapse, New England Spinal Metastasis Score (NESMS) at presentation, and treatment strategy. RESULTS: We included 202 patients. Twenty-three percent of the population had died by 3 months following treatment initiation, 51% by 1 year, and 70% at 2 years. There was no significant difference in survival between patients treated operatively and nonoperatively (P = 0.16). No significant difference in HRQL between groups was appreciated beyond 3 months following treatment initiation. NESMS at presentation (scores of 0 [HR 5.61; 95% CI 2.83, 11.13] and 1 [HR 3.00; 95% CI 1.60, 5.63]) was significantly associated with mortality. CONCLUSION: We found that patients treated operatively and nonoperatively for spinal metastases benefitted from treatment in terms of HRQL. Two-year mortality for the cohort as a whole was 70%. When prognosticating survival, the NESMS appears to be an effective utility, particularly among patients with scores of 0 or 1.Level of Evidence: 2.

Zone 2 Flexor Tendon Repair Location and Risk of Catching on the A2 Pulley.

PURPOSE: To determine the region of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in zone 2 that, when involved by a laceration repair, will reliably catch on the A2 pulley after surgery. METHODS: Using fresh-frozen cadavers (5 hands, 20 digits), excursions of the FDP and FDS tendons were measured in relation to the A2 pulley. The C1, A3, and C2 pulleys were resected. The digit was maximally flexed by applying traction to the flexor tendon in the forearm. An 8-0 suture tag was placed in the flexor tendons immediately distal to the A2 pulley. The digit was then passively fully extended to measure tendon excursion. Measurements were repeated with 50% venting and 100% release of the A4 pulley. Reference points such as tendon insertions and flexion creases were obtained. This protocol was repeated sequentially for the index, middle, ring, and little fingers. RESULTS: For all 20 fingers, the suture placed into the FDP just distal to the A2 pulley with the finger fully flexed traveled 1.6 ± 1.9 mm distal to the proximal edge of the A4 pulley with passive extension of the finger. The mean excursion for the FDP was 24.6 ± 3.2 mm, and 16.9 ± 3.1 mm for the FDS. The mean A2 pulley length was 16.2 ± 3.5 mm, and the mean distance between the distal edge of the A2 pulley and the proximal edge of the A4 pulley was 23.0 ± 3.3 mm. Venting the A4 pulley 50% and 100% increased FDP excursion a maximum of 0.9 and 1.9 mm, respectively. CONCLUSIONS: An FDP repair proximal to the A4 pulley will slide under the A2 pulley with full active digital flexion after surgery. If the distal FDP stump lies underneath the A4 pulley with the digit fully extended, the FDP repair will not likely engage the A2 pulley with full flexion after surgery. The FDP excursion can be reliably predicted as a percentage of the A2 (distal) to the A4 (distal) pulley distance. Most importantly, the distance between the repair site and the A4 pulley approximately equals the length of the A2 pulley that requires release to avoid postoperative triggering. CLINICAL RELEVANCE: Knowledge of this high-risk region of flexor tendon repair will guide surgeons regarding the potential need for partial release of the A2 pulley.