Amputation Characteristics Vary by Branch of Service - Chad A. Krueger, MD; James R. Ficke, MD; and Joseph C. Wenke, PhD

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This study examines the amputees from the Army and Marine Corps, the two military branches that have sustained the majority of combat-related amputations. All U.S. service members who sustained major extremity amputations from October 2001 through July 2011 were analyzed. Amputation levels, demographics, and mounted or dismounted status at injury were examined. There were 835 Army and 344 Marine amputees; 52.9% of all Marine amputees occurred during 2010 and 2011. Over 50% of Marine and 44% of Army amputees sustaining an amputation during 2010 and 2011 sustained multiple amputations. Dismounted service members had significantly (p < .0001) higher Injury Severity Scores and were significantly more likely to sustain double (p D .0082) and triple (p < .0001) amputations than mounted personnel. Marine amputees were significantly (p < .0001) more likely to be dismounted than Army amputees. The number of multiple amputees increased substantially in 2010 and 2011. Marine amputees, particularly dismounted, are at an increased risk of sustaining multiple amputations. Key words: amputation trends, multiple amputee, war amputations

Evidence-Based Medicine in Military Orthopaedics: Are We Doing Our Part? - David J. Tennent, MD; James R. Bailey, MD; James R. Ficke, MD; and Daniel J. Stinner

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The clinical application of evidence-based medicine is influenced by the quality of the published literature. Journals assign objective levels of evidence tos to describe the quality and reliability of individuals. Studies assigned levels I to III are considered higher quality studies. This study reviewed 60 continuous years of the American edition of the Journal of Bone and Joint Surgery to analyze trends in the quality of research published by U.S. military orthopaedic surgeons. Three hundred and six of 371 identifieds were assigned a level of evidence from I to V. These were then analyzed to determine if military orthopaedic surgeons were producing higher quality studies over time. Over time, the total number ofs published decreased. However, the number of higher quality studies and average level of evidence per decade improved over time. This trend toward publishing higher quality studies is consistent with the general orthopaedic community and highlights the need for continued work by the military orthopaedic community to conduct higher quality studies. Key words: evidence-based medicine, levels of evidence, military

Outcome of Minimally Invasive Hip Replacement in Obese, Overweight, and Nonobese Patients - Marc W. Hungerford, MD; Reinhard Schuh, MD; Michael P. O’Reilly, MD; Lynne C. Jones, PhD

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Abstract: The goal of this study was to determine whether obesity affects implant positioning or early functional outcome after minimally invasive total hip replacement. The authors evaluated 119 patients who had undergone minimally invasive total hip replacement via a direct anterior approach. The patients were segregated according to World Health Organization body mass index categories: nonobese, overweight, or obese. Perioperative variables, resulting cup position, and early outcome (Harris Hip Score) were assessed. The only significant difference among the groups was mean operative time (obese > overweight > nonobese). Although the obese group’s 2-year Harris Hip Score was the lowest, all patients had good to excellent results. In conclusion, minimally invasive hip replacement in obese patients provides early outcomes comparable to those in nonobese patients. Key words: body mass index, minimally invasive surgery, obesity, outcomes, total hip replacement

Pelvic Crescent Fractures: Variations in Injury Mechanism and Radiographic Pattern - Rick J. Gehlert, MD; Zhiqing Xing, MD; and Thomas A. DeCoster, MD

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Pelvic crescent fracture, also known as sacroiliac fracture–dislocation, is traditionally considered as a lateral compression injury and a vertically stable injury. Thirty consecutive cases were analyzed and it was found that 63% of cases were caused by lateral compression (LC), 27% by anteroposterior compression (APC), and 10% by vertical shear (VS). APC and VS injuries cause significant displacement of the anterior iliac fragment, but 21% of LC injury cases showed minimal displacement and were treated successfully with nonoperative treatment. Different injury mechanisms also produce different types of pelvic instability. More important, different injury mechanisms produce distinct radiographic fracture patterns regarding the obliquity of the fracture line and fracture surface. These differences in the fracture pattern will influence the decision of internal fixation options. Therefore, treatment of pelvic crescent fractures should be based on individual analysis of injury mechanism and radiographic fracture pattern. Key words: crescent fracture, injury mechanism, pelvic fracture

Effect of Head and Neck Positioning on Cerebral Perfusion During Shoulder Arthroscopy in Beach Chair Position - Dane Salazar, MD; Benjamin Sears, MD; Anna Acost

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The aim of this prospective cohort study was to investigate the effect of head and neck positioning on cerebral perfusion during shoulder arthroscopy in the beach chair position. Regional cerebral tissue oxygen saturation (rSO2) was monitored intraoperatively using near-infrared spectroscopy on 51 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position. The head of each subject was manipulated by the examiner and sequentially positioned for 45 seconds in terminal flexion, extension, bilateral rotation, and bilateral lateral bending. Decreases in rSO2 of 20% or greater from baseline were defined as a cerebral desaturation event (CDE). The association between head and neck position and cerebral perfusion was assessed. Eight percent of patients (4/51) experienced CDE during head and neck positioning. Body mass index was found to be a risk factor for CDE (p D .05). When comparing preoperative baseline rSO2 to intraoperative supine and intraoperative upright rSO2, there was no significant decrease in saturation levels for any of the six tested positions. Frequent intraoperative evaluations of the head and neck position as well as careful preoperative positioning may reduce the risk of position-related complications in patients undergoing elective shoulder arthroscopy in the beach chair position. In this study’s patient population, however, head and neck position was not found to cause significant cerebral desaturation for the time period tested compared to preoperative baselines. Key words: beach chair, cerebral perfusion, oxygen saturation, shoulder arthroscopy

Brachial Plexus Injury: A Descriptive Study of American Football - Harlan M. Starr, Jr., MD; Blake Anderson, MD; Ron Courson, ATC; and John G.

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A stinger is a common, yet understudied, injury that involves stretching or compression of the brachial plexus, often occurring during contact sports. Five football teams, including high school, collegiate, and professional teams, completed questionnaires. Questions were designed to obtain descriptive information regarding the nature and consequence of this injury and assess effectiveness of current preventive measures. Three hundred and four surveys were returned with 153 players reporting a stinger in their career (50.3%). The prevalence increased with years played and was most common in running backs (69%), defensive linemen (60%), linebackers (55%), and defensive secondary (54%). Current protective equipment and neck-strengthening programs did not provide protective benefits. Players at greatest risk of developing a stinger include those having played 3 or more years and players whose primary position is running back, defensive back, or defensive lineman. Further study is needed to better evaluate the effectiveness of current preventive measures. Key words: brachial plexus neurapraxia, football, nerve injury, shoulder and neck injury, stinger

Use of Emergency Department Services for Hand, Wrist, and Forearm Fractures in the United States in 2008 - Igor Immerman, MD; Meryl S. Livermore, MD; and Robert

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The objective of this study was to determine demographic characteristics and epidemiology of hand, wrist, and forearm fracture patients treated in the emergency departments (EDs) to identify the at-risk populations. The Nationwide Emergency Department Sample database collected by the Agency for Healthcare Research and Quality was used to estimate ED visits for hand, wrist, and forearm fractures during 2008. The overall rate of ED visits for these injuries was 54 per 10,000 population. Children aged 6 to 15 had the highest rate of ED visits at 124 per 10,000. A secondary increase in ED visits occurred at age 50 and rose with age. Metacarpals were the most common fracture location in adults aged 16 to 25, while radius and ulna were the most common fracture location in all other age groups. Demographic analysis identified children, adult males aged 16 to 25, and the elderly as target populations for preventive interventions. Key words: emergency department, epidemiology, forearm fractures, hand fractures, wrist fractures

"‘Zone of Vulnerability"’ for Radial Nerve Injury: Anatomic Study - S. Ashfaq Hasan, MD; Russell B. Rauls, MD; Cari L. Cordell, MD; Mark S. Bailey, MD; and Thao

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The authors of this study sought improved understanding of the radial nerve course through the brachium and hypothesized that the most proximal aspect of the triceps tendon (PATT) serves as a useful superficial landmark for localizing the nerve. It was also hypothesized that a poorly appreciated area of vulnerability for nerve injury exists where the radial nerve runs along the lateral cortex of the humerus proximal to its transit through the lateral intermuscular septum (LIMS). The authors assessed 33 fresh-frozen cadaveric specimens. A 6.7-cm span of the nerve lies directly on the periosteum of the humerus before piercing the LIMS. The proximal 4.6 cm abuts the posterior cortex. The final 2.1 cm just proximal to the LIMS runs along the lateral cortex. The nerve at the posterior midline of the humerus is 2.3 cm proximal to the level of the PATT. The radial nerve lies directly on the lateral humeral cortex for 2 cm proximal to its transit through the LIMS. The PATT appears to be a consistent and practical superficial landmark to determine the location of the radial nerve from a posterior approach. Key words: anatomy, iatrogenic injury, radial nerve, triceps tendon, zone of vulnerability

Papillary Endothelial Hyperplasia in Association With Vascular Malformation of the Hand - Kristin Alves, MD; Andrea Bauer, MD; and Jesse Jupiter, MD

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Vascular malformations are uncommonly encountered in the hand. This case report involves the unique case of a rapidly enlarging mass associated with a known vascular malformation. Final pathology revealed dense reactive fibrous tissue, with prominent blood vessels, consistent with a venous malformation and associated papillary endothelial hyperplasia. The intraoperative finding of two separately identifiable masses, one fibrotic and one vavscular, has not previously been reported. Key words: papillary endothelial hyperplasia, pseudoangiosarcoma, vascular malformation

Anterior Intrapelvic Migration of Femoral Trial Head Requiring Secondary Surgical Approach for Retrieval - Johannes F. Plate, MD, PhD; Daniel N. Bracey, MD; Ann

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The current report describes a revision total hip arthroplasty in which the trial femoral head disassociated during reduction and migrated into a soft tissue capsule of the true pelvis between the external iliac vein and corona mortise. The authors believe this previously undescribed migration pattern was created by the patient’s history of recurrent dislocations. To retrieve the trial prosthesis without injuring the adjacent vasculature, a secondary surgical approach was utilized. The described case identifies the risk of pelvic migration in patients with a history of dislocations and reminds us that a secondary surgical approach should be considered to avoid devastating injury to the neighboring vasculature. Key words: complication, disassociation, revision, total hip arthroplasty

Adhesive Capsulitis - Stephen J. Pomeranz, MD, and Neeraj Modi, MD

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Adhesive capsulitis of the shoulder, commonly known as ‘‘frozen shoulder’’ or ‘‘frozen shoulder syndrome,’’ is a self-limited painful condition that is quite common. In 1984, the prevalence of frozen shoulder was demonstrated at slightly greater than 2% in the general population. In the authors’ practice, consisting primarily of orthopedic magnetic resonance imaging, this diagnosis is frequently seen in patients referred for evaluation of rotator cuff tear because the presenting symptoms are similar. Key words: adhesive capsulitis, shoulder pain

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