Brian R. Waterman

Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan: A study of 2,089 instances of spine trauma

BACKGROUND This study sought to characterize spine injuries among soldiers killed in Iraq or Afghanistan whose autopsy results were stored by the Armed Forces Medical Examiner System. METHODS The Armed Forces Medical Examiner System data set was queried to identify American military personnel who sustained a spine injury in conjunction with wounds that resulted in death during deployment in Iraq or Afghanistan from 2003 to 2011. Demographic and injury-specific characteristics were abstracted for each individual identified. The raw incidence of spinal injuries was calculated and correlations were drawn between the presence of spinal trauma and military specialty, mechanism and manner of injury, and wounds in other body regions. Significant associations were also sought for specific injury patterns, including spinal cord injury, atlantooccipital injury, low lumbar vertebral fractures, and lumbosacral dissociation. Statistical calculations were performed using &khgr;2 statistic, z test, t test with Satterthwaite correction, and multivariate logistic regression. RESULTS Among 5,424 deceased service members, 2,089 (38.5%) were found to have sustained at least one spinal injury. Sixty-seven percent of all fatalities with spinal injury were caused by explosion, while 15% occurred by gunshot. Spinal fracture was the most common type of injury (n = 2,328), while spinal dislocations occurred in 378, and vertebral column transection occurred in 223. Fifty-two percent sustained at least one cervical spine injury, and spinal cord injury occurred in 40%. Spinal cord injuries were more likely to occur as a result of gunshot (p < 0.001), while atlantooccipital injuries (p < 0.001) and low lumbar fractures (p = 0.01) were significantly higher among combat specialty soldiers. No significant association was identified between spinal injury risk and the periods 2003 to 2007 and 2008 to 2011, although atlantooccipital injuries and spinal cord injury were significantly reduced beginning in 2008 (p < 0.001). CONCLUSION The results of this study indicate that the incidence of spinal trauma in modern warfare seems to be higher than previously reported. LEVEL OF EVIDENCE Epidemiologic study, level III.

Management and prevention of acute and chronic lateral ankle instability in athletic patient populations

Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significant long-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and non-anatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation.

Objective: The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF). Methods: The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures. Results: Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m2 (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19–15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13–4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95–19.35), open wound (OR: 5.04; 95% CI: 2.25–11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31–6.93), and smoking (OR: 2.85; 95% CI: 1.42–5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m2, bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes. Conclusions: Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Spinal injuries in United States military personnel deployed to Iraq and Afghanistan: an epidemiological investigation involving 7877 combat casualties from 2005 to 2009.

Study Design. Retrospective analysis of a prospective data set. Objective. Determine the incidence and epidemiology of combat-related spinal injuries for the wars in Afghanistan and Iraq. Summary of Background Data. Recent studies have identified a marked increase in the rate of combat-related spine trauma among casualties in Afghanistan and Iraq. Limitations in these previous works, however, limit their capacity for generalization. Methods. A manual search of casualty records stored in the Department of Defense Trauma Registry was performed for the years 2005 to 2009. Demographic information, nature of spinal wounding, injury mechanism, concomitant injuries, year, and location of injury were recorded for all soldiers identified as having sustained combat-related spine trauma. Incidence rates were constructed by comparing the frequencies of spine casualties against defense manpower deployment data. Multivariate Poisson regression was used to identify statistically significant factors associated with spinal injury. Results. In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000. Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confidence interval: 1.68–2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39–33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confidence interval: 1.55–2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02). Conclusion. The incidence of spine trauma in modern warfare exceeds reported rates from earlier conflicts. The study design and population size may enhance the capacity for generalization of our findings. Level of Evidence: 3

Simulation Training Improves Surgical Proficiency and Safety During Diagnostic Shoulder Arthroscopy Performed by Residents

Although virtual reality simulators have established construct validity, no studies have proven transfer of skills from a simulator to improved in vivo surgical skill. The current authors hypothesized that simulation training would improve residents basic arthroscopic performance and safety. Twenty-two orthopedic surgery trainees were randomized into simulation or standard practice groups. At baseline testing, all of the participants performed simulator-based testing and a supervised, in vivo diagnostic shoulder arthroscopy with video recording. The simulation group subsequently received 1 hour of total instruction during a 3-month period, and the standard practice group received no simulator training. After intervention, both groups were reevaluated with simulator testing and a second recorded diagnostic shoulder arthroscopy. Two blinded, independent experts evaluated arthroscopic performance using the anatomic checklist, Arthroscopic Surgery Skill Evaluation Tool (ASSET) score, and total elapsed time. All outcome measures were compared within and between groups. After intervention, mean time required by the simulation group to complete the simulator task (30.64 seconds) was 8±1.2 seconds faster than the time required by the control group (38.64 seconds; P=.001). Probe distance (51.65 mm) was improved by 41.2±6.08 mm compared with the control (92.83 mm; P=.001). When comparing ASSET safety scores, the simulation group was competent (3.29) and significantly better than the control group (3.00; P=.005) during final arthroscopic testing. This study establishes transfer validity for an arthroscopic shoulder simulator model. Simulator training for residents in training can decrease surgical times, improve basic surgical skills, and confer greater patient safety during shoulder arthroscopy. [Orthopedics. 2016; 39(3):e479-e485.].

Sternoclavicular Reconstruction in the Young Active Patient: Risk Factor Analysis and Clinical Outcomes at Short-Term Follow-up.

Objective: To determine the functional outcomes in young, active individuals after sternoclavicular (SC) joint reconstruction. Design: Level IV, case series. Setting: United States military hospitals, 2008–2012. Patients/Participants: Retrospective review of all consecutive patients from the Military Health System Management Analysis and Reporting Tool was performed. Patients who underwent other open-shoulder procedures (eg, acromioclavicular joint reconstruction), those of nonmilitary or retired status, and patients with under 12-month minimum follow-up without medical separation were excluded from further analysis. Intervention: Open reconstruction of SC joint dislocation. Main Outcome Measures: Primary outcomes of interest were clinical failure and medical separation due to persistent shoulder girdle dysfunction. Demographic data, surgical technique, outcomes, complications, and occupational military outcomes were recorded. Results: Fourteen patients, with an average age of 26 years, experienced 8 anterior (57.1%) and 6 posterior (42.9%) SC joint dislocations. Four patients (28.6%) presented with dysphagia or dyspnea, and 10 patients (71.4%) had a missed diagnosis with an average of 13 months until diagnosis. Twelve of 14 (85.7%) patients underwent figure-of-eight tendon reconstruction, and 10 (71.4%) were able to return to full active military duty at an average 26.8 ± 12.9 months follow-up. There were 6 complications in 5 patients (35.7%), whereas 2 (14.3%) reported persistent instability and 2 (14.3%) required reoperation. Conclusions: SC joint dislocations are rare injuries that are frequently missed on clinical presentation in this study. However, acute or delayed surgical reconstruction may afford predictable rates of return to function in young active military service members. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Hospital Readmission After Total Shoulder Arthroplasty

The study was conducted to determine the incidence rate, risk factors, and postoperative conditions associated with 30-day readmission after total shoulder arthroplasty (TSA). A total of 3547 patients who underwent primary TSA were identified from the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program. The 30-day readmission rate was 2.9%. The only preoperative predictors of hospital readmission were American Society of Anesthesiologists classification of 3 or greater (odds ratio, 2.16; 95% confidence interval, 1.30-3.61) and a history of cardiac disease (odds ratio, 2.13; 95% confidence interval, 1.05-4.31). Of patients with any perioperative complications, 42 (34%) were readmitted, and the presence of any complication increased the risk of readmission (odds ratio, 28.95; 95% confidence interval, 18.44-45.46). Periprosthetic joint infection, myocardial infarction, pulmonary embolism, deep venous thrombosis, and pneumonia were significant predictors of hospital readmission after TSA (P<.0001). The incidence of hospital readmission after TSA peaked within the first 5 days after discharge, and 26%, 32%, and 55% of all hospital readmissions occurred by postoperative days 5, 7, and 14, respectively. Pre-operative medical optimization to reduce the rates of postoperative complications, such as periprosthetic joint infection, myocardial infarction, pulmonary embolism, deep venous thrombosis, pneumonia, and urinary tract infection, are likely to decrease the need for subsequent readmission. Patients should be counseled about these risk factors preoperatively. [Orthopedics. 2017; 40(1):e1-e10.].

Performance and return to sport in elite baseball players and recreational athletes following repair of the latissimus dorsi and teres major

BACKGROUNDnTears of the latissimus dorsi (LD) and teres major (TM) are rare but disabling injuries in the overhead athlete.nnnMETHODSnAll patients who underwent an LD and/or TM repair between January 1, 2010, and June 6, 2016, with more than 12 months follow-up were included. Demographic information and postoperative range of motion were recorded. Patients were contacted via phone and answered questions to provide the following: Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow outcome score, American Shoulder and Elbow Surgeons (ASES) shoulder score, and visual analog scale (VAS) score. Performance data for professional athletes were recorded preoperatively and postoperatively and compared by paired t tests.nnnRESULTSnEleven male patients aged 29.9u2009±u200912.4 years were included; 86% were right hand dominant, 86% underwent surgery on the dominant side, and 73% were pitchers (7 professional and 1 collegiate). The mean time from injury to repair was 389u2009±u2009789 days; 36% of repairs were performed within 6 weeks of injury. At final follow-up, the VAS score was 0.7u2009±u20091.9, the ASES score was 100u2009±u20090, and the KJOC score was 93u2009±u20095. Professional (major and minor league) pitchers had a mean total time participating in professional baseball of 6.6u2009±u20093.9 years, with 3.9u2009±u20092.3 years before surgery and 2.7u2009±u20091.8 years after surgery. Among professional pitchers, the VAS pain score was 0.0u2009±u20090.0, the ASES score was 100u2009±u20090, and the KJOC score was 89u2009±u20092. All professional pitchers returned to the same level of play. No significant differences existed between any preoperative and postoperative performance metrics for pitchers (Pu2009>u2009.05).nnnCONCLUSIONnRepair of LD and TM tears in both professional and recreational athletes produces reliable functional recovery with minimal pain and the ability to return to preoperative athletic activity, even among elite throwing athletes.

Prevention and management of post-instability glenohumeral arthropathy

Post-instability arthropathy may commonly develop in high-risk patients with a history of recurrent glenohumeral instability, both with and without surgical stabilization. Classically related to anterior shoulder instability, the incidence and rates of arthritic progression may vary widely. Radiographic arthritic changes may be present in up to two-thirds of patients after primary Bankart repair and 30% after Latarjet procedure, with increasing rates associated with recurrent dislocation history, prominent implant position, non-anatomic reconstruction, and/or lateralized bone graft placement. However, the presence radiographic arthrosis does not predict poor patient-reported function. After exhausting conservative measures, both joint-preserving and arthroplasty surgical options may be considered depending on a combination of patient-specific and anatomic factors. Arthroscopic procedures are optimally indicated for individuals with focal disease and may yield superior symptomatic relief when combined with treatment of combined shoulder pathology. For more advanced secondary arthropathy, total shoulder arthroplasty remains the most reliable option, although the clinical outcomes, wear characteristics, and implant survivorship remains a concern among active, young patients.

The Epidemiology and Natural History of Anterior Shoulder Instability

Purpose of ReviewThe purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability.Recent FindingsRecent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well.SummaryThere are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.