Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Acromion morphology is associated with glenoid bone loss in posterior glenohumeral instability.

BACKGROUND: The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability. METHODS: This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL ≥13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage. RESULTS: Patients without GBL had a steeper acromial tilt (58.5° ± 1.4°) compared with those with 0%-13.5% GBL (64.3° ± 1.5°) or GBL ≥13.5% (67.7° ± 1.8°) (P = .004). Patients without GBL also had greater posterior coverage (65.4° ± 1.7°) compared with those with GBL (60.3° ± 1.4°) (P = .015). Posterior acromion height was not significantly different among groups. CONCLUSION: The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue-stabilizing procedures.

Acute Simple Elbow Dislocations in the United States: An Epidemiological Analysis of Trends Including COVID-19.

Background Elbows are one of the most frequently dislocated large joints; however, there is limited epidemiological data, especially during the coronavirus disease 2019 (COVID-19) pandemic. This study characterizes elbow dislocations presenting to Emergency Departments (EDs) over the last decade. Methods This study is a cross-sectional, descriptive, epidemiologic analysis of isolated elbow dislocations presenting to EDs from 2011-2020 using the National Electronic Injury Surveillance System (NEISS) database. Patients under 10, those with radial head subluxation, and those with complex fractures were excluded. Data on incidence ratios, patient demographics, mechanisms of injury, and incident locales were analyzed. Results Approximately 83,996 simple, primary elbow dislocations occurred from 2011-2020 (n=2,328), generating an incidence of 2.98/100,000 person-years. Incidence was higher among males (3.26 versus 2.69/100,000 person-years). Dislocations peaked in patients aged 10-19, with higher rates in males (11.12 versus 5.31/100,000 person-years; injury rate ratio 2.09, CI=2.05-2.14, p<0.001). Rates of elbow dislocations decreased with age in males (age 20-29=11.12, age >80=0.63/100,000) but increased in females over 40 (age 40-49=1.59, age 70-79=2.83/100,000). Athletic activities accounted for 55% of dislocations (n=45,902), with 15% from football and 14% from wrestling. The fewest annual dislocations occurred during COVID-19 (n=6440). Injuries occurring at schools and during contact and indoor sports decreased, while those from soccer increased. Conclusions Elbow dislocations are common, with trends of decreasing incidence with age among men and increasing incidence in women over 40. COVID-19 impacted sports-related and epidemiologic injury patterns. Ultimately, understanding population-level risks for elbow dislocations enables orthopaedic surgeons to predict injury trends and conceive educational preventative measures.

Global assessment of military and civilian trauma systems integration: a scoping review.

BACKGROUND: The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators. METHODS: A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers. RESULTS: Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%). CONCLUSION: Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.

A 25-Year Analysis of Diversity, Equity, and Inclusion Research in Orthopaedics Shows Majority Female Authorship and Increasing Gender Parity Research.

Introduction: Orthopaedic surgery is one of the least diverse fields in medicine. In recent decades, there has been a concerted effort to increase diversity, equity, and inclusion (DEI) in the specialty, in addition to the institution of several organizations to establish the pipeline and facilitate underrepresented minority students into orthopaedic surgery. The aim of this study was to examine trends in orthopaedic surgery DEI research. Methods: A search of DEI articles was conducted in orthopaedic surgery using PubMed, MEDLINE, EMBASE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Education Resources Information Center. The year of publication, article topic of focus, sex of the primary author, publishing journal, citation index, and primary contributing institution were recorded for each article. Sex of the primary author was predicted by the authors using an online image search of the author and institution. Articles were excluded if the research was conducted outside of the United States or if they were not specific to orthopaedic surgery. Results: A total of 143 articles met the inclusion criteria. A total of 52.4% of authors (n = 75) were women and 44.1% (n = 63) were men. A total of 42.7% of the articles were written about sex (n = 61), 39.9% about race/ethnicity and sex (n = 57), and 11.9% about race/ethnicity (n = 17). A total of 10 articles were affiliated with Washington University in St. Louis while 51 other institutions wrote the remaining articles, with none having more than 4. Information could not be confirmed for 5 articles. In 2018, 5 articles were published, followed by 17 in 2019, 25 in 2020, 34 in 2021, and 30 in 2022. Conclusion: DEI research in orthopaedic surgery is a relatively new venture within the specialty and has room to grow, specifically in the examination of race/ethnicity and inclusion strategies. Leading journals and academic institutions in orthopaedic surgery should incentivize productivity and authorship in DEI research. Level of Evidence: III.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival.

Background: To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid. Methods: All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes. Results: The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients. Conclusion: Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Incidence of sports-related sternoclavicular joint dislocations in the United States over the last two decades.

BACKGROUND: Epidemiological understanding of acute sternoclavicular (SC) dislocations secondary to sports across the United States is poorly defined. AIM: To identify and assess epidemiological trends of SC dislocations occurring secondary to sports-related mechanisms across United States over the past two decades. METHODS: This cross-sectional, descriptive epidemiological study evaluates epidemiological trends of SC dislocations from sports that present to emergency departments (EDs) across the United States. Data were obtained from the National Electronic Injury Surveillance System database spanning two decades. Data on incidence, patient demographics, mechanisms of injury, dislocation types, incident locales, and patient dispositions were collected. RESULTS: 1622 SC dislocations occurred nationwide from 2001 to 2020 [incidence = 0.262/1000000 people, confidence interval (CI) = 0.250-0.275], comprising 0.1% of shoulder/upper trunk dislocations. Most patients were male (91%, n = 1480) and aged 5-17 (61%, n = 982). Football, wrestling, and biking were the most frequently implicated sports, with contact sports responsible for 59% of athletic injuries (n = 961). Recreational vehicle-related sports injuries, such as all-terrain vehicles, dirt bikes, and mopeds accounted for 7.8% of all injuries (n = 126), with dirt bikes specifically comprising 3.7% (n = 61). Ultimately, 82% were discharged from the ED (n = 1337), 12% were admitted (n = 194), and 6% were transferred (n = 90). All recorded posterior dislocations were admitted or transferred from the ED. Patients sustaining SC dislocations from contact sports had a significantly increased risk of hospital admission or transfer rather than discharge from the ED as compared to patients whose injuries were from non-contact sports (incidence rate ratio = 1.46, CI: = 1.32-1.61, P < 0.001). CONCLUSION: SC dislocations from sports continue to be rare with a stably low incidence over the past two decades, likely comprising a smaller proportion of shoulder dislocations than previously thought. Contact sports are a frequent source of injury, especially among school-aged and teenage males. Most patients are discharged directly from the ED; however, a substantial number are hospitalized, many of which had documented posterior dislocations. Ultimately, understanding the epidemiology and mechanism-related trends of acute SC dislocations is important given the potential severity of these injuries, concentration in a specific population, and uncertainty linked to rare presentation.

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.

Lower Reoperation and Higher Return-to-Sport Rates After Biceps Tenodesis Versus SLAP Repair in Young Patients: A Systematic Review.

Purpose: To evaluate patient-reported outcomes, return to sport, and adverse events after SLAP repair versus biceps tenodesis (BT) in a young patient population undergoing treatment of SLAP tears. Methods: We performed a systematic review and meta-analysis of the PubMed (MEDLINE), Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for comparative studies discussing outcomes after SLAP repair and BT in patients younger than 40 years with at least 1 year of follow-up. Results: Four studies were included, comprising a total of 274 patients who underwent treatment of SLAP tears with SLAP repair (169 patients) or BT (105 patients). Most patients were male patients (79.8%) and athletes (74.5%). Preoperative and postoperative pain visual analog scale scores decreased similarly in both groups (range, 6.6-6.7 preoperatively to 0.8-2.6 postoperatively in SLAP repair group vs 5.6-7.3 preoperatively to 0.7-1.9 postoperatively in BT group). Similar and substantial American Shoulder and Elbow Surgeons Standardized Shoulder Assessment score increases were observed after both procedures (range, 40.6-45.8 preoperatively to 75.4-92.0 postoperatively in SLAP repair vs 41.9-55.0 preoperatively to 85.7-91.2 postoperatively in BT group). Patient satisfaction rates were similar but showed slightly higher ranges after BT (8.5-8.8 vs 8.0-8.2). Rates of return to sport were higher after BT (63%-85% vs 50%-76%), with higher odds of returning to sport after BT reported by all studies. Surgical complications were rare after SLAP repair and BT. Rates of reoperation were substantially higher after SLAP repair (3%-15% vs 0%-6%), with 3 of 4 studies reporting no reoperations after BT. BT comprised 78% to 100% of reoperation procedures after SLAP repair. Conclusions: Postoperative pain, function, and patient satisfaction were similar after SLAP repair and BT in patients younger than 40 years. There are higher rates of reoperation and lower rates of return to sport after SLAP repair than after BT. Level of Evidence: Level III, systematic review of Level III studies.

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.

A New Normal: Trends of Upper Extremity Orthopaedic Injuries Nationwide During the COVID-19 Pandemic.

Background The widespread societal effects of the COVID-19 pandemic connote public health and epidemiological changes for orthopedic injuries. The epidemiology of upper extremity injuries and the effects of the pandemic on these nationwide trends is poorly defined. Methods This cross-sectional, descriptive epidemiological study compares epidemiological trends among upper extremity (UE) orthopedic injuries presenting to emergency departments (EDs) prior to and during the COVID-19 pandemic. Upper extremity fracture and dislocation data was sourced from the National Electronic Injury Surveillance System (NEISS) database in years prior to (2015-2019) and during the pandemic (2020-2021). Data on incidence, patient demographics, injury patterns, mechanisms of injury, incident locale, and patient disposition were collected and compared between years. Results The pre-COVID-19 incidence rate (IR) of UE fractures at 2.03 per 1,000 persons (n=3038930 from 2015-2019) decreased to 1.84 per 1,000 in 2020 (n=474805) and 1.82 per 1,000 in 2021 (n=471793). Dislocation rates were largely unchanged at 0.34 per 1,000 people (n=476740) prior to the pandemic and with incidence rates of 0.33 per 1,000 (n=85582) and 0.34 per 1,000 (n=89386) in 2020 and 2021, respectively. Female patients over 65 had the highest injury IR at 4.85 per 1,000 (n=976948). Finger fractures (IR=0.38 per 1000, n=96009) overtook hand fractures (IR=0.51 per 1000, n=310710) as more common during COVID-19 in males, while wrist (IR=0.55 per 1000, n=350650) fractures remained most common in females. Injuries from individual sports, such as skateboarding and bicycling, increased during the pandemic, while injuries from team sports decreased. Hospital admission and observation increased in 2020, while discharge and transfer rates decreased. Admission, observation, and discharge rates moved closer to pre-pandemic levels in 2021. Conclusions The COVID-19 pandemic was associated with epidemiological and activity changes regarding UE fractures and dislocations presenting to EDs. The present study demonstrates notable decreases in rates of upper extremity fractures and dislocations, increases in rates of injuries related to outdoor and individual sports such as skateboarding with corresponding decreases in rates of injuries related to organized sports such as basketball, increases in the rates of injuries occurring in homes and in association with pet supplies, and decreases in rates of injuries occurring in schools and places of recreation observed during the pandemic. Additionally, trends observed among patient disposition specific to the pandemic, such as increasing rates of patient admission, observation, and against medical advice (AMA) departure with decreasing rates of discharge and transfer, offer insight into the burden of upper extremity injuries on the healthcare system during this critical time. While upper extremity orthopedic injuries remained common through the pandemic, the early pandemic was associated with higher rates of hospital admission that normalized closer to pre-pandemic levels by 2021, which may herald a shift and return to pre-pandemic trends. Future research will determine the long-term downstream effects of COVID-19 on activity-related orthopedic injuries and bone health.

Tenosynovial Giant-Cell Tumor Presenting as Septic Arthritis of the Knee.

Tenosynovial giant-cell tumor (TGCT) is an intraarticular giant-cell tumor of the synovial tissue and tendon sheaths which often mimics multiple conditions on presentation. This case report describes a previously asymptomatic 67-year-old man with preliminary clinical and laboratory evaluation suggestive of septic arthritis; however, arthroscopy revealed diffuse synovitis, and biopsy confirmed TGCT. To our knowledge, this is the first report of TGCT presenting as septic arthritis in an adult patient. This diagnosis should be considered in evaluation of acute, atraumatic knee pain with associated inflammatory marker elevation.

Tranexamic acid administration and pulmonary embolism in combat casualties with orthopaedic injuries.

In combat casualty care, tranexamic acid (TXA) is administered as part of initial resuscitation effort; however, conflicting data exist as to whether TXA contributes to increased risk of venous thromboembolism (VTE). The purpose of this study is to determine what factors increase risk of pulmonary embolism after combat-related orthopaedic trauma and whether administration of TXA is an independent risk factor for major thromboembolic events. SETTING: United States Military Trauma Centers. PATIENTS: Combat casualties with orthopaedic injuries treated at any US military trauma center for traumatic injuries sustained from January 2011 through December 2015. In total, 493 patients were identified. INTERVENTION: None. MAIN OUTCOME MEASURES: Occurrence of major thromboembolic events, defined as segmental or greater pulmonary embolism or thromboembolism-associated pulseless electrical activity. RESULTS: Regression analysis revealed TXA administration, traumatic amputation, acute kidney failure, and hypertension to be associated with the development of a major thromboembolic event for all models. Injury characteristics independently associated with risk of major VTE were Injury Severity Score 23 or greater, traumatic amputation, and vertebral fracture. The best performing model utilized had an area under curve  = 0.84, a sensitivity=0.72, and a specificity=0.84. CONCLUSIONS: TXA is an independent risk factor for major VTE after combat-related Orthopaedic injury. Injury factors including severe trauma, major extremity amputation, and vertebral fracture should prompt suspicion for increased risk of major thromboembolic events and increased threshold for TXA use if no major hemorrhage is present. LEVEL OF EVIDENCE: III, Prognostic Study.

Primary Pulmonary Thrombus in Combat Casualties: Is Treatment Necessary?

The objective of this study was to describe the natural history of primary pulmonary thrombus (PPT) in combat casualties. This was a retrospective study of casualties treated at a major military treatment facility from 2010 to 2012. Patients with a downrange chest CT were included. CTs were reviewed by two independent, blinded radiologists to confirm PPT on initial imaging. Follow-up CTs, if obtained, were also independently reviewed to determine the extent of clot burden. Two hundred and forty-nine casualties with a downrange, acceptable quality chest CT were included. 9 per cent (23/249) of patients sustained PPT. Thirty nine per cent (9/23) were initially treated with therapeutic anticoagulation (AC). Conversely, 61 per cent (14/23) arrived to our military treatment facility without AC. Seven arriving without AC-developed pulmonary symptoms during their hospitalization and had interval chest CTs. Of those, three had no evidence of pulmonary thrombus. The other four had subsegmental filling defects and three were started AC whereas one had an IVC (Inferior Vena Cava) filter inserted. In total, 11/23 (48%) PPT patients were managed without AC and discharged without complications. This is the first study attempting to look at PPT natural history. There were no adverse sequelae from managing PPT without AC. Further studies are warranted to further characterize PPT.