The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage.

PURPOSE: Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population. METHODS: We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations. RESULTS: A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury. CONCLUSIONS: Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal Fibular Metastasis of Colorectal Carcinoma: A Case Report.

Case: A 62-year-old woman presenting with ankle pain was initially treated for a non-displaced fracture. Persistent pain despite months of conservative management for her presumed injury prompted repeat radiographs which demonstrated the progression of a lytic lesion and led to an orthopedic oncology referral. Following a complete work-up, including biopsy and staging, she was diagnosed with colorectal carcinoma metastatic to the distal fibula. Conclusion: Secondary tumors of the fibula are uncommon but an important diagnosis to consider for intractable lower extremity pain especially in patients with history of malignancy or lack of age-appropriate cancer screening.

Technical Trick: Cryoneurolysis for Subacute Pain Mitigation in Patients With Limb Loss.

SUMMARY: Pain after amputation is often managed by target muscle reinnervation (TMR) with the added benefit that TMR also provides improved myoelectric terminal device control. However, as TMR takes several months for the recipient muscles to reliably reinnervate, this technique does not address pain within the subacute postoperative period during which pain chronification, sensitization, and opioid dependence and misuse may occur. Cryoneurolysis, described herein, uses focused, extreme temperatures to essentially "freeze" the nerve, blocking nociception, and improving pain in treated nerves potentially reducing the chances of pain chronification, sensitization, and substance dependence or abuse.

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.

Preoperative malnutrition increases odds of hospital admission and extended length of stay following arthroscopic rotator cuff repair.

BACKGROUND: Rotator cuff repair (RCR) is a common orthopedic procedure frequently performed in the outpatient setting. Malnutrition, as assessed by preoperative serum albumin <3.5 g/dL, has been independently associated with significantly higher risks of multiple adverse outcomes in several orthopedic procedures. The effect of preoperative hypoalbuminemia on short-term outcomes of RCR was previously unknown. HYPOTHESIS: we hypothesized that preoperative serum albumin <3.5 g/dL would be associated with higher odds of post-operative admission and prolonged length of stay. METHODS: This study represents a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) for patients undergoing RCR between 2011 and 2015. RESULTS: Multivariate regression analysis adjusted for sex, ASA classification, age, BMI, and diabetes status (Table 3) showed preoperative hypoalbuminemia conferred a significantly increased adjusted odds ratio of postoperative admission (adjusted odds ratio 1.711, CI 1.134-2.583, p = 0.011) and extended length of stay (adjusted odds ratio 2.073, CI 1.073-4.003, p = 0.030). CONCLUSION: Malnutrition as assessed by preoperative serum albumin <3.5 g/dL is significantly associated with increased odds of hospital admission and extended length of stay following arthroscopic RCR. This has clinical implications in surgical patient selection and risk stratification. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015.

BACKGROUND: Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients. HYPOTHESIS: We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity. RESULTS: A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001). CONCLUSION: Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.

Shoulder and Elbow Injuries in the Adolescent Throwing Athlete.

Shoulder and elbow injuries in the adolescent population can be generally divided into skeletally immature and skeletally mature. Skeletally immature injuries refer to damage to the open growth plate (physis) in the young athlete, which have distinct differences in long-term risks if not managed correctly due to the potential for growth disturbance. Skeletally mature injuries occur in athletes with closed growth plates and are less likely to limit growth potential. It is important to recognize these different types of injuries, as well as the patients most at risk for each type because treatment may vary significantly between the two groups. The main skeletally immature injuries covered by this review will include: medial epicondyle apophysitis ("Little Leaguer's elbow), medial epicondyle fractures, olecranon stress fractures, capitellar osteochondritis dissecans (OCD), and proximal humeral apophysitis ("Little Leaguer's shoulder"). The skeletally mature injuries discussed will include: valgus extension overload syndrome (VEOS), ulnar collateral ligament (UCL) tear, shoulder instability, and superior labral anterior-posterior (SLAP) tears. We will review the history and presentation of the injuries as well as different treatment strategies and return to play guidelines for both primary care sports physicians as well as orthopedic surgeons.