Volume 23-3, Fall 2014

The primary mission of deployed military orthopaedic surgeons in a combat zone is to treat musculoskeletal battlefield trauma and associated wartime injuries. The role of humanitarian surgical care during combat operations has not been defined. An anonymous online survey was sent to databases containing all U.S. military active-duty orthopaedic surgeons as well as to members of the Society of Military Orthopaedic Surgeons. Inclusion criteria for the study were defined as at least one deployment to Iraq (Operation Iraqi Freedom, OIF) or Afghanistan (Operation Enduring Freedom, OEF). Three hundred fifty-six invitations were sent with 107 orthopaedic surgeons completing the survey. Respondents reported approximately 3,000 humanitarian surgeries performed in the combat zone, with 70% to 80% involving chronic deformity and nonunion surgeries. Seventy-nine percent of the respondents believed that humanitarian surgery was a key component of the mission, improved skills (73%), benefited population (76%), and improved security (61%). A significant amount of humanitarian surgery in the combat zone has been performed in OEF/OIF. Key words: combat orthopaedic surgery, Global War on Terror, humanitarian surgery, military surgery

Spine-related disability for military personnel injured in combat is not known. The goal of this study was to characterize spine-related disability in a cohort of soldiers wounded in recent military operations. The authors reviewed the U.S. Army Physical Evaluation Board database medical discharge records of 450 wounded soldiers for long-term disability causing a medical discharge from active duty service. Fourteen percent of the cohort had at least one spine-related disability resulting in medical discharge from the military. For the 54 unfitting conditions attributed to back pain, 33% had no precipitating injury. Eighteen soldiers had a spinal cord injury, 10 of which were complete. The average percent disability for back pain was 11%, and the average disability for a spinal cord injury was 77%. Twenty-one percent of the soldiers with spine-related disability also had disability attributed to psychological conditions. Spine-related disability is common after combat injury, though not all spine disability is directly related to an actual injury. Spinal cord injury with persistent neurological dysfunction results in higher permanent disability. Key words: back pain, combat wounds, spine disability, spine injury

Traditional manual instruments for total knee arthroplasty are associated with a malalignment rate of nearly 30%. Patient-specific positioning guides, developed to help address alignment, may also influence other intraoperative factors. This study compared a consecutive series of 270 Vanguard total knee replacements performed with Signature patient-specific positioning guides (study group) to a consecutive series of 595 similar knee replacements performed with manual instrumentation (control group). The study group averaged 16.7 fewer minutes in the operating room (p < .001), utilized tibial inserts that averaged 0.4 mm thinner with a smaller proportion of ‘‘thick’’ tibial inserts (14–18 mm) (p < .001), and required fewer transfusions (p D .022). The Signature-derived surgical plan accurately predicted correct femoral and tibial component sizes in 86.3% and 70.3% of the cases, respectively. These rates increased to 99.3% and 99.2%, respectively, for accuracy to within one size of the surgical plan, similar to published values for manual instrumentation. Key words: patient-specific positioning guides, Signature system, total knee arthroplasty, Vanguard knee

One specimen from each of six pairs of cadaveric shoulders underwent a semitendinosus coracoclavicular ligament reconstruction with a hook plate used for acromioclavicular joint reduction, while on the other specimen a polydioxanone (PDS) suture braid was utilized. Cyclical loading followed by maximal load-to-failure testing was performed. Displacement during cyclical loading, loads to 50% and 100% displacement, stiffness, and maximal load to failure were determined for all specimens. Results showed that the locking hook plate allowed significantly less displacement of the coracoclavicular interval during cyclical loading (3.41 vs. 9.67 mm, p D .0081) and withstood significantly higher loads before both 50% (225.5 vs. 107.7 N, p D .0197) and 100% displacement (410.6 vs. 240.1 N, p D .0077). The locking hook plate was found to be significantly stiffer than the PDS suture braid (28.2 vs. 18.4 N/mm, p D .0029), but there was no difference in maximal load to failure between the two fixation methods (hook plate, 434.4 N; PDS, 476.7 N; p D .76). Key words: acromioclavicular, biomechanical, coracoclavicular, hook plate

To examine whether anchors used in arthroscopic Bankart repair increased the risk of subsequent fracture, six intact polyurethane scapulae and six with three 3.0-mm suture anchors placed along the anteroinferior glenoid were compared. An axial load of 1 mm/s was applied to the anteroinferior glenohumeral joint with a prosthetic humeral head. Outcome measures were force needed for initial fracture and catastrophic failure, percent of anterior glenoid bone loss, and fracture length. With the numbers available, no significant differences could be detected between groups in yield load or maximum load. The anchor group had a significantly larger percentage of bone loss (p <.01) and fracture length (p < .01) compared to the intact group. In this study, anchors did not decrease force needed to fracture but did lead to significantly larger fractures of the anterior glenoid during a simulated dislocation event. Further study using various anchors and techniques is warranted. Key words: anchors, arthroscopy, Bankart repair, biomechanics, glenoid fracture, shoulder dislocation, shoulder instability

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1–L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patient’s persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis. Key words: Mycobacterium kansasii, Pott’s disease, sarcoidosis, vertebral osteomyelitis

Recent advances in magnetic resonance imaging (MRI) allow detection of changes in molecular matrix of cartilage and thus allow the earliest detection of its breakdown. These MRI techniques are collectively referred to as ‘‘cartilage mapping,”which attempts to designate a qualitative assessment of cartilage at each given location on the cartilage surface. These qualitative abnormalities can occur even in the setting of normal cartilage thickness and morphology. This article introduces the molecular biology behind this new technique, discusses some potential clinical applications, and discusses value added over traditional MRI cartilage evaluation. Key words: cartilage, chondral, mapping, matrix, molecular, proteoglycan, T2, type 2 collagen

Typically, rotator cuff repair is performed two-dimensionally while visualizing the subacromial space. To achieve a more complete repair, sutures can be retrieved from inside the joint utilizing a penetrating suture device through the anterolateral portal, which permits visualization of the articular side and bursal side of the rotator cuff tear. Utilizing other portals can leave the sutures out of sight and reach. The anterolateral portal helps capture both leaves of a delaminated tear and places the sutures in the center of the field for retrieval and tying. The anterolateral portal is located with a spinal needle just off the anterolateral corner of the acromion, and the suture anchor is inserted into the greater tuberosity through this portal. The sutures are passed into the joint through the tear in the rotator cuff with a suture grasper. The scope is redirected intraarticularly, and the suture is visualized. The sutures are positioned, and the penetrator is passed through the tendon. The scope is placed back in the bursa for tying sutures and capturing both leaves of a delaminated tear. It works equally well for simple complete tears and partial articular-sided supraspinatus tendon avulsion lesions. Key words: anterolateral portal, bursal, delaminated, PASTA, rotator cuff, shoulder arthroscopy