The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Outcomes Following Modified Broström for Chronic Lateral Ankle Instability With and Without Peroneal Tendon Exploration.

BACKGROUND: It is not known how peroneal tendon exploration influences results after modified Broström for lateral ankle instability. We propose peroneal exploration at the time of modified Broström will have similar outcomes as no peroneal exploration. METHODS: A retrospective analysis was performed of patients undergoing modified Broström with and without peroneal exploration. Foot and Ankle Outcome scores and data regarding military retention were gathered and compared. RESULTS: Seventeen patients were identified in the modified Broström only cohort and 24 in the peroneal exploration cohort. Patients had mean follow-up of 5 years in both cohorts. The mean FAOS in the modified Broström only cohort was 68 and 72 in the cohort with peroneal exploration (P = .541). When each FAOS subcategory was analyzed, no difference was identified in any subcategory. Eight of 17 patients (47%) in the modified Broström only cohort remained active duty compared with 8 of 24 patients (33%) in the modified Broström with peroneal exploration cohort (P = .518). One patient medically discharged in the modified Broström only cohort versus 6 in peroneal exploration cohort (P = .109). Overall satisfaction with the procedure was 12 of 17 (71%) in the modified Broström only cohort and 19 of 24 (79%) in the peroneal exploration cohort (P = .529). CONCLUSIONS: No significant difference was identified between patients undergoing modified Broström alone or modified Broström with peroneal exploration. There was no significant difference in return to duty, medical discharge or patient satisfaction. LEVELS OF EVIDENCE: Level III: retrospective case-control study with prospectively collected data.

Biceps Squeeze Tenotomy: Technique to Improve Efficiency of Arthroscopic Biceps Tenotomy.

Biceps tenotomy is a common procedure performed in arthroscopic shoulder surgery. Numerous studies have demonstrated the effectiveness of both biceps tenotomy and tenodesis to relieve pain and restore function for the diagnoses of bicipital tenosynovitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs. It is also frequently performed as a concomitant procedure with arthroscopic rotator cuff repair. We report a technique to improve the efficiency of arthroscopic bicep tenotomy using a biceps squeeze maneuver. This is a simple method of manually squeezing the biceps muscle belly while performing the arthroscopic biceps tenotomy. This shortens and tensions the intra-articular portion of the tendon to facilitate a more safe and efficient procedure.

Uncomplicated Arthroscopic Rotator Cuff Repair in Chronic Ipsilateral Upper Extremity Lymphedema: A Case Report.

CASE: A 69-year-old woman with chronic upper extremity lymphedema secondary to bilateral mastectomy and axillary lymph node dissection for breast cancer 10 years before presented to the clinic with a massive rotator cuff tear. Her shoulder pain and dysfunction persisted despite nonoperative treatment. She underwent left shoulder arthroscopic rotator cuff repair (RCR) and biceps tenotomy. Arm, forearm, and wrist circumference measurements were obtained, preoperatively, immediately postoperatively, and 1-week and 2-weeks postoperatively. No permanent increase in extremity circumference measurements was observed. CONCLUSION: This case suggests that it is possible to perform an arthroscopic RCR in a patient with chronic upper extremity lymphedema without creating further morbidity.

Biomechanical Evaluation of Unicortical Stress Risers of the Proximal Humerus Associated With Pectoralis Major Repair.

Proximal humerus fracture after pectoralis major tendon repair has been recently reported. Although this complication is rare, it may be possible to decrease such risk using newer techniques for myotenodesis. This study was designed to evaluate various unicortical stress risers created at the proximal humeral metadiaphysis during myotenodesis for repair of pectoralis major ruptures. A simulated pectoralis major myotenodesis was performed using fourth-generation Sawbones (N=30). Using previously described anatomic landmarks for the tendinous insertion, 3 repair techniques were compared: bone trough, tenodesis screws, and suture anchors (N=10 each). Combined compression and torsional load was sequentially increased until failure. Linear and rotational displacement data were collected. The average number of cycles before reaching terminal failure was 383 for the bone trough group, 658 for the tenodesis group, and 832 for the suture anchor group. Both the tenodesis and the suture anchor groups were significantly more resistant to fracture than the bone trough group (P<.001). The suture anchor group was significantly more resistant to fracture than the tenodesis group (P<.001). All test constructs failed in rotational stability, producing spiral fractures, which incorporated the unicortical defects in all cases. When tested under physiologic parameters of axial compression and torsion, failure occurred from rotational force, producing spiral fractures, which incorporated the unicortical stress risers in all cases. The intramedullary suture anchor configuration proved to be the most stable construct under combined axial and torsional loading. Using a bone trough technique for proximal humerus myotenodesis may increase postoperative fracture risk. [Orthopedics. 2017; 40(5):e801-e805.].