Volume 22-1, Spring 2013 (free)

Identification of Optimal Control Compartments for Serial Near-Infrared Spectroscopy Assessment of Lower Extremity Compartmental Perfusion - Keith Jackson II, MD

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A femoral neck stress fracture is a serious condition that affects military personnel and endurance athletes. There is increasing evidence that femoroacetabular impingement contributes to significant hip pathology. This study investigates the prevalence of radiographic abnormalities associated with impingement in military personnel treated for femoral neck stress fractures. The radiographs of 69 consecutive soldiers being treated for a femoral neck stress fracture identified on magnetic resonance imaging were reviewed for radiographic signs of femoroacetabular impingement. In the cohort, the average incidence of a crossover sign was 51% (27/53). The incidence of a center edge angle greater than 40° was 47% (25/53). The alpha angle was greater than 50° in 55% (29/53). In conclusion, it appears that young patients with femoral neck stress fractures have a high prevalence of radiographic abnormalities suggestive of hip impingement. Hip impingement may lead to abnormal stress across the femoral neck, predisposing individuals to stress fractures. Key words: FAI, femoral acetabular impingement, femoral neck stress, hip, stress fractures

Outcomes Following Cervical Disc Arthroplasty in an Active Duty Military Population - Daniel G. Kang, MD; Ronald A. Lehman, Jr., MD; Robert W. Tracey, MD;

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As part of the physical education program at the United States Military Academy, all cadets complete a movement training course designed to develop skills and improve performance in military-related physical tasks as well as obstacle navigation. The purpose of this study was to determine if completion of this course would also result in changes in jump-landing technique that reduce the risk of anterior cruciate ligament (ACL) injury. Analysis of landing mechanics on a two-footed jump landing from a height of 30 cm with a three-dimensional motion capture system synchronized with two force plates revealed both positive and negative changes. Video assessment using the Landing Error Scoring System (LESS) revealed an overall improved landing technique (p D .001) when compared to baseline assessments. The studied military movement course appears to elicit mixed but overall improved lower extremity jump-landing mechanics associated with risk for ACL injury. Key words: ACL, biomechanics, military, prevention

Functional Outcomes of Hip Arthroplasty in Active Duty Military Service Members - Anton Y. Jorgensen, MD; Brian R. Waterman, MD; Mark S. Hsiao, MD;

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A retrospective review was performed to evaluate the outcomes and complications following heterotopic ossification (HO) resection and lysis of adhesion procedures for posttraumatic contracture, after combatrelated open elbow fractures. From 2004 to 2011, HO resection was performed on 30 blast-injured elbows at a mean 10 months after injury. Injuries included 8 (27%) Gustilo-Anderson type II fractures, 8 (27%) type III-A, 10 (33%) III-B, and 4 (13%) III-C. Mean preoperative flexion–extension range of motion (ROM) was 36.4°, compared with mean postoperative ROM of 83.6°. Mean gain of motion was 47.2°. Traumatic brain injury, need for flap, and nerve injury did not appear to have a significant effect on preoperative or postoperative ROM. Complications included one fracture, six recurrent contractures, and one nerve injury. The results and complications of HO resection for elbow contracture following high-energy, open injuries from blast trauma are generally comparable to those reported for HO resection following lower energy, closed injuries. Key words: combat-related injury, elbow, elbow contracture, heterotopic ossification, trauma

Achillon Mini-Open Achilles Tendon Repair: Early Outcomes and Return to Duty Results in U.S. Military Service Members - Justin D. Orr, MD; Brendan McCriskin, MD

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The purpose of this study was to compare the outcomes of manipulation under anesthesia (MUA) to arthrolysis for combat-related arthrofibrosis. Sixty-one knees in 56 patients who underwent treatment for arthrofibrosis secondary to lower extremity trauma were reviewed. Knee range of motion preoperatively, postoperatively, and at follow-up was analyzed. The primary outcome measure was the difference in knee arc of motion between the two cohorts. Forty-one knees (67.2%) underwent MUA and 20 knees (32.8%) were managed operatively. There was no difference in the preoperative arc of motion. Knees that underwent MUA had significant improvements in arc of motion compared to knees that underwent arthrolysis (106.3° vs. 82.3°) at a follow-up of 2 years (p D .008). The complication rate was greater in knees that underwent arthrolysis (40%) compared to knees that underwent MUA (12.2%; p D .04). In conclusion, knees that underwent MUA demonstrated significant improvements in arc of motion at 2-year follow-up with fewer complications. Key words: arthrofibrosis, arthrolysis, knee range of motion, manipulation under anesthesia

Heterotopic Ossification Resection After Open Periarticular Combat-Related Elbow Fractures - Kevin W. Wilson, MD; Jonathan F. Dickens, MD; Reed Heckert, MD;

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Symptomatic cervical radiculopathy is a common problem in the active duty military population and can cause significant disability leading to limited duty status and loss of operational readiness and strength. Based on their increasing experience with cervical disc arthroplasty (CDA) in this unique patient population, the authors set out to further evaluate the outcomes and complications of CDA in active duty military patients. A retrospective review of a single military tertiary medical center was performed between August 2008 and August 2012 and the clinical outcomes of patients who underwent cervical disc arthroplasty were evaluated. There were 37 active duty military patients, with a total of 41 CDA. The study found good relief of preoperative symptoms (92%) and the ability to maintain operational readiness with a high rate of return to full unrestricted duty (95%) with an average follow-up of 6 months. There was a low rate of complications related to the anterior cervical approach (5%–8%), with no deviceor implant-related complications. Key words: active duty military, cervical disc arthroplasty, cervical disc replacement, degenerative disc disease, radiculopathy, return to duty

Outcomes of Manipulation Under Anesthesia Versus Surgical Management of Combat-Related Arthrofibrosis of the Knee - Korboi N. Evans, MD, MS; Louis Lewandowski

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Military service members have increased requirements of shoulder weight bearing to perform duties. Operative intervention has increased for treatment of displaced middle one-third clavicle fractures. Complications of operatively treated clavicle fixation have not been extensively studied. A retrospective, longitudinal cohort chart evaluation was conducted of all active duty members undergoing fixation of middle one-third clavicle fractures, for complications between intramedullary pin fixation and plate constructs. This review found 62 patients meeting inclusion criteria. Thirty-three patients underwent intramedullary pin fixation with Hagie pins and 31 patients underwent precontoured superior clavicle plate fixation of their middle one-third clavicle fractures. Complications included wound infection, skin and/or soft tissue irritation, and need for unplanned hardware removal. The overall complication rate was 31% in the plate fixation group versus 9% in the intramedullary pin group (p D .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group. Key words: clavicle, intramedullary, military, operative fixation

Acute Compartment Syndrome of the Thigh in Combat Casualties - Brendan D. Masini, MD; Adam W. Racusin, MD; Joseph C. Wenke, PhD; Tad L. Gerlinger, MD;

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The purpose of this article is to report short-term outcomes and return to duty rates in a cohort of active duty U.S. military personnel who underwent repair of acute Achilles tendon ruptures using the Achillon mini-open technique. Between October 2009 and March 2012, 15 consecutive patients underwent mini-open repair of acute Achilles tendon ruptures using the Achillon device by a single surgeon. Minor and major complications were recorded, and American Orthopaedic Foot and Ankle Society (AOFAS) and pain visual analog scores were recorded at regular follow-up intervals. At mean latest follow-up of 16.7 months postoperatively, all 15 patients had returned to full active duty status without major complications. Specifically, no patient experienced major wound complication, infection, or rerupture. Mean AOFAS score in 9 of 15 patients was 94.1; mean pain visual analog score in 12 of 15 patients was 1.4. The Achillon mini-open technique can be used for treatment of acute Achilles tendon ruptures in appropriately selected high-demand patient populations with the expectation of minimal adverse outcomes. Key words: Achilles tendon, Achillon, military, mini-open, rupture

Tibial Stress Fractures in an Active Duty Population: Long-Term Outcomes - Kelly G. Kilcoyne, MD; Jonathan F. Dickens, MD; and John-Paul Rue, MD

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Acute compartment syndrome of the thigh is a rare clinical entity often caused by high-energy trauma and presenting with a spectrum of associated injuries. Service members in combat are at risk for these causative mechanisms. This study presents a large cohort of thigh compartment syndrome combat casualties and investigates the injury mechanisms, associated mortality, and complications related to fasciotomies. Blasts were the most frequent injury mechanism, overall mortality was 23%, burns were associated with a higher mortality, and fasciotomy morbidity was reported by all respondents. The mortality was similar to civilian cohorts with thigh compartment syndrome and was isolated to patients with high Injury Severity Scores. While mortality associated with this injury is high, it is likely related to associated injury patterns rather than the compartment syndrome itself. Thigh compartment fasciotomies carried significant morbidity, consistent with civilian trauma publications. Key words: combat trauma, fasciotomy, thigh compartment syndrome

Prevalence of Radiographic Findings Consistent With Femoroacetabular Impingement in Military Personnel With Femoral Neck Stress Fractures - Timothy Carey, DO;

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In chronic pectoralis tendon tears, primary repair may not be possible and allograft reconstruction may be required. The goal of this study was to report the authors’ experience with chronic pectoralis major tendon reconstructions using an Achilles tendon allograft in three military patients. Three consecutive patients presenting with chronic, complete pectoralis major tendon tears underwent reconstruction by a single surgeon using the same described technique at a mean of 22.2 months after initial injury. Final outcomes were assessed at a mean of 24.5 months postoperatively, yielding one excellent and two good results. All patients were satisfied. All patients returned to full active duty military service and recreational weight lifting by 6 months. Achilles allograft reconstruction of chronic pectoralis major tendon ruptures is a viable treatment option. Good to excellent results can be achieved in active patients, even when reconstruction is performed nearly 2 years from the time of injury. Key words: Achilles, allograft, chronic, pectoralis, reconstruction, rupture, tear

Anterior Cruciate Ligament Augmentation for Rotational Instability Following Primary Reconstruction With an Accelerated Physical Therapy Protocol - Timothy Care

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The purpose of the present study is to present the results of anterior cruciate ligament (ACL) augmentation for patients having rotational instability despite an intact vertical graft in lieu of conventional revision ACL reconstruction. ACL augmentation surgery with a horizontal graft was performed to augment a healed vertical graft on five patients and an accelerated rehabilitation protocol was instituted. Functional outcomes were assessed by the Lower Extremity Functional Scale (LEFS) and the Modified Cincinnati Rating System (MCRS). All patients completed physical therapy within 5 months and were able to return to full military duty without limitation. LEFS and MCRS were significantly improved. ACL augmentation with a horizontal graft provides an excellent alternative to ACL revision reconstruction for patients with an intact vertical graft, allowing an earlier return to duty for military service members. Key words: ACL, anterior cruciate ligament reconstruction, augmentation, double bundle, revision reconstruction, rotational instability

Military Movement Training Program Improves Jump-Landing Mechanics Associated With Anterior Cruciate Ligament Injury Risk - Brett D. Owens, MD; Kenneth L. Camer

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Optimal treatment for acromioclavicular (AC) dislocation is unknown. Numerous surgical procedures for AC injuries have been described with little comparison. This study sought to compare the clinical and radiographic results of various surgical techniques in order to identify the optimal surgical technique. Ninety patients met inclusion criteria of AC reconstruction at this institution. A retrospective review of outcomes was performed using the electronic records system. Radiographs were measured for pre- and postoperative grade and percent elevation versus the contralateral side. Overall revision rate was 9%. Suture button fixation had a revision rate of 0% compared to 14% (p D .01). Reconstruction procedures performed with distal clavicle excision showed a higher revision rate, 17% compared to 0% (p D .003). There were no statistically significant clinical differences. AC reconstructions performed with suture button construct were superior to other surgical techniques. Procedures performed with distal clavicle excision were inferior to those without. Key words: acromioclavicular, dislocation, distal clavicle resection, reconstruction, shoulder separation

Surgical Technique Affects Outcomes in Acromioclavicular Reconstruction - Jason A. Grassbaugh, MD; Chad Cole, PA-C; Kurt Wohlrab, MD; and Josef Eichinger, MD

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Many of the orthopaedic studies completed within the military come from records-based research. This methodological article will assist researchers in completing such studies by highlighting the experiences and lessons learned from a recent retrospective study on amputees. Specifically, this article provides details on the various data sources available within the military, and how to access those systems, and offers general advice for the completion of retrospective studies using Department of Defense data systems. Although there are many obstacles that need to be overcome in order to successfully complete records-based research within the military, the authors hope this article will aid investigators in the completion of future projects. Key words: chart review, methodology, research design, retrospective research

Comparison of Complication Rates of Intramedullary Pin Fixation Versus Plating of Midshaft Clavicle Fractures in an Active Duty Military Population - Jerome J.

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Near-infrared spectroscopy (NIRS) has shown promise in detecting ischemic changes in acute compartment syndrome. The objectives of this study were to 1) assess the correlation in NIRS values between upper and lower extremity control sites for bilateral lower extremity trauma and 2) investigate the effect of skin pigmentation on NIRS values. Forty-four volunteers (14 male, 30 female) were monitored over separate 1-hour sessions. NIRS leads were placed over leg and upper extremity compartments. Colorimeters were used to document skin pigmentation. NIRS values between corresponding contralateral compartments were extremely well correlated (r D 0.76–0.90). Upper extremity NIRS values were correlated to leg values in the following order: volar (r D 0.65–0.71), dorsal (r D 0.36–0.60), and deltoid (r D 0.42–0.51). A negative correlation was observed between melanin and NIRS values. Analogous leg compartments are the optimal site of control for each other. The volar forearm may be the best upper extremity control. Skin pigmentation may affect absolute NIRS values. Key words: acute compartment syndrome, adipose tissue, control sites, near-infrared spectroscopy, skin pigmentation

Completing Records-Based Research Within the Military: A User’s Guide - Chad A. Krueger, MD; Wendy Ching, MS; and Joseph C. Wenke, PhD

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There are few reports on outcomes after hip arthroplasty in the military population despite increases among young, active patients. U.S. Army service members with coded hip arthroplasty between 2004 and 2010 were reviewed. Patient demographic variables were correlated with occupational outcomes. Of 183 patients, the occupational outcomes at a minimum 2 years postoperatively for service members undergoing primary hip arthroplasty were medically separated (n D 44, 24%), retired (n D 82, 45%), and returned to active duty (n D 57, 31%). Multivariate analysis identified that age less than 40 years [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.14, 10.12] and enlisted rank (OR, 3.63; 95% CI, 1.29, 10.20) as major independent risk factors for medical separation. Univariate analysis revealed that officer rank had an increased likelihood of postoperative combat deployment than enlisted rank (OR, 3.39; 95% CI, 1.50, 7.94). Despite encouraging results in the civilian literature, this study documents modest retention rates on active duty at a minimum of 2 years after primary hip arthroplasty. Key words: functional outcome, hip arthroplasty, military, occupational, physical activity

Allograft Reconstruction of Chronic Pectoralis Major Tendon Ruptures - Michael A. Zacchilli, MD; Justin T. Fowler, MD; and Brett D. Owens, MD

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Tibial stress fractures are a common overuse injury among military recruits. The purpose of this study was to determine what, if any, long-term effects that tibial stress fractures have on military personnel with respect to physical activity level, completion of military training, recurrence of symptoms, and active duty service. Twenty-six military recruits included in a previous tibial stress fracture study were contacted 10 years after initial injury and asked a series of questions related to any long-term consequences of their tibial stress fracture. Of the 13 patients available for contact, no patients reported any necessary limited duty while on active duty, and no patient reported being separated or discharged from the military as a result of stress fracture. Tibial stress fractures in military recruits are most often an isolated injury and do not affect ability to complete military training or reflect a long-term need for decreased physical activity. Key words: stress fracture, tibia

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