Chad A. Krueger

Late amputation may not reduce complications or improve mental health in combat-related, lower extremity limb salvage patients☆

INTRODUCTIONnFollowing severe lower extremity trauma, patients who undergo limb reconstruction and amputations both endure frequent complications and mental health sequelae. The purpose of this study is to assess the extent to which late amputation following a period of limb salvage impacts the evolution of the clinical variables that can affect the patients perception of his or her limb: ongoing limb associated complications and mental health conditions.nnnPATIENTS AND METHODSnA case series of US service members who sustained a late major extremity amputation from September 2001 through July 2011 were analysed. Pre- and post-amputation complications, mental health conditions, and reason(s) for desiring amputation were recorded.nnnRESULTSnForty-four amputees with detailed demographic, injury and treatment data were identified. The most common reasons for desiring a late amputation were pain and being dissatisfied with the function of the salvage limb. An average of 3.2 (range 1-10) complications were reported per amputee prior to undergoing late amputation and an average of 1.8 (range 0-5) complications reported afterwards. The most common complication prior to and after late amputation was soft tissue infection (24 (17%) and 9 (22%), respectively). Twenty-nine (64%) late amputees were diagnosed with a mental health condition prior to undergoing their amputation and 27 (61%) late amputees were diagnosed with mental conditions after late amputation. Only three of the 15 patients who did not have a mental health condition documented prior to their late amputation remained free of a documented mental health condition after the amputation.nnnDISCUSSIONnOngoing complications and mental health conditions can affect how a patient perceives and copes with his or her limb following severe trauma. Patient dissatisfaction following limb reconstruction can influence the decision to undergo a late amputation. Patients with a severe, combat related lower extremity injury that are undergoing limb salvage may not have a reduction in their overall complication rate, a resolution of specific complications or an improvement of their mental health after undergoing late amputation.nnnCONCLUSIONnSurgeons caring for limb salvage patients should counsel appropriately when managing expectations for a patient who desires a late amputation.

Venous thromboembolism during combat operations: a 10-y review

BACKGROUNDnThis article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data.nnnMETHODSnA retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated.nnnRESULTSnAmong 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07-2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35-3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3-3.32).nnnCONCLUSIONSnCombat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.

Characterisation and outcomes of upper extremity amputations

BACKGROUNDnThe purpose of this study is to characterise the injuries, outcomes, and disabling conditions of the isolated, combat-related upper extremity amputees in comparison to the isolated lower extremity amputees and the general amputee population.nnnMETHODSnA retrospective study of all major extremity amputations sustained by the US military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, and the Physical Evaluation Board Liaison Offices were queried in order to obtain injury characteristics, demographic information, treatment characteristics, and disability outcome data.nnnRESULTSnA total of 1315 service members who sustained 1631 amputations were identified; of these, 173 service members were identified as sustaining an isolated upper extremity amputation. Isolated upper extremity and isolated lower extremity amputees had similar Injury Severity Scores (21 vs. 20). There were significantly more non-battle-related upper extremity amputees than the analysed general amputation population (39% vs. 14%). Isolated upper extremity amputees had significantly greater combined disability rating (82.9% vs. 62.3%) and were more likely to receive a disability rating >80% (69% vs. 53%). No upper extremity amputees were found fit for duty; only 12 (8.3%) were allowed continuation on active duty; and significantly more upper extremity amputees were permanently retired than lower extremity amputees (82% vs. 74%). The most common non-upper extremity amputation-related disabling condition was post-traumatic stress disorder (PTSD) (17%). Upper extremity amputees were significantly more likely to have disability from PTSD, 13% vs. 8%, and loss of nerve function, 11% vs. 6%, than the general amputee population.nnnDISCUSSION/CONCLUSIONnUpper extremity amputees account for 14% of all amputees during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts. These amputees have significant disability and are unable to return to duty. Much of this disability is from their amputation; however, other conditions greatly contribute to their morbidity.

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques

HYPOTHESISnIt is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons.nnnMETHODSnNine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique.nnnRESULTSnThere were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps.nnnDISCUSSIONnThis study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.

Initial injury severity and social factors determine ability to deploy after combat-related amputation

OBJECTIVEnWhile many recent publications have examined the ability of amputees to return to active duty, it remains largely unknown why few amputees deploy after amputation and many amputees do not. The purpose of this study is to examine what predictor(s) exist for whether or not an amputee will deploy after sustaining a combat-related amputation.nnnMETHODSnAll U.S. Service members who sustained major extremity amputations from September 2001 through July 2011 were analysed. Amputation level(s), mechanism of injury, time interval to amputation, age, rank, Physical Evaluation Board (PEB) disposition and ability to deploy after amputation were determined.nnnRESULTSnDeployment information after amputation was obtained for 953 amputees. There were 47 (5%) amputees who deployed. There were no significant differences amongst service branches for the deployment of amputees (p > 0.2). Amputees who underwent their amputation on the same day of their injury were significantly less likely to deploy after amputation than those who had their amputation on the day of injury (p = .01). Deployed amputees had significantly lower Injury Severity Scores than amputees who did not deploy (15.98 vs 20.87, p < 0.01) and officers were significantly (p < .01) more likely to deploy and the average age of amputees who deployed was significantly higher than those who did not (27.5 vs 25.1, p < .01). Lastly, those amputees who sustained a transtibial amputation were significantly more likely to deploy than all other amputation levels (p < .01). Nine out of 19 (47%) Special Forces amputees were able to deploy.nnnDISCUSSIONnThe vast majority of amputees do not able to deploy after undergoing amputation. The main predictors of deploying after sustaining a combat-related amputation appear to be: sustaining a transtibial amputation, being of senior rank or age and being a member of the Special Forces. Many of these factors appear to be non-treatment related and highlight the importance that individual and social factors play in the recovery of severe injuries.

Is There an Association Between Study Materials and Scores on the American Board of Orthopaedic Surgeons Part 1 Examination

BACKGROUNDnPrevious studies have shown that certain orthopaedic in-training examination scores can be used to identify which residents may be at risk for failing the American Board of Orthopaedic Surgeons (ABOS) Part 1 examination. However, no studies have examined how study resources may affect residents ABOS Part 1 scores. The goal of this study is to determine which review sources or review courses, if any, are associated with improved ABOS Part 1 scores.nnnMETHODSnA survey was sent to 221 of the 865 examinees who took the ABOS Part 1 examination in 2012. The questions inquired the respondents how well they performed on previous orthopaedic in-training examinations and ABOS Part 1, along with the study sources they most commonly used, review courses they attended, and resources they would recommended if they were to retake ABOS Part 1 examination.nnnRESULTSnOverall, 118 of the 221 (53%) survey recipients completed the survey. Six (5%) of the respondents failed ABOS Part 1 examination. Orthobullets and the American Academy of Orthopaedic Surgeons self-assessment examinations were recommended as the primary study source significantly more (p < 0.01) than most other resources, but there was no significant association between study source and passing ABOS Part 1 or scoring in a certain percentile on ABOS Part 1. Similarly, there were no associations between attending a review course and either passing or scoring in a certain percentile for ABOS Part 1. Half of the respondents who failed ABOS Part 1 attended multiple review courses.nnnCONCLUSIONSnThere does not appear to be an association between improved ABOS Part 1 scores and orthopedic study materials or review courses. Further research into the value of certain educational modalities should be conducted to determine the best ways to educate orthopedic residents and determine the value of some of these commonly used orthopedic review modalities.

What to Read and How to Read It: A Guide for Orthopaedic Surgeons

With the increasing amount of information available to orthopaedic surgeons, the choice of what to read can seem difficult bordering on overwhelming. As orthopaedic surgery continues to evolve toward a more evidence-based education system, deciding what information resources to use is ever more important. Many orthopaedic surgeons have had little formal instruction on what educational resources to read or how to best understand the information and assimilate it into their practice. This lack of knowledge may contribute to difficulties when trying to learn a topic, develop a plan of care, build a knowledge base for patient care, or develop a method for maintenance reading. This article reviews the rationale for using evidence-based medicine, explores the different types of educational resources available to orthopaedic surgeons, and delivers insight into the science of reading. This information should aid orthopaedic surgeons in using peer-reviewed publications to aid in their decision-making processes.nnAlthough the exponential rise in publications has added immense knowledge to the field of orthopaedic surgery, the influx of data has made staying current with the literature very difficult. A few recent articles have attempted to address this issue1-3. There are more than 100 orthopaedic journals indexed on MEDLINE4, and more than 12,000 articles were published in orthopaedic or sports medicine journals in 20135. In addition, more than 600 of the orthopaedic surgery books available on Amazon.com were published in 2014 alone6. For an orthopaedic surgeon, reading only the articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS) and Clinical Orthopaedics and Related Research would equate to reading approximately 120 articles per month. For a specialist primarily focused on reading The American Journal of Sports Medicine and Arthroscopy, there are nearly sixty articles to read per month. If this …

Disability Associated with Musculoskeletal Injuries

Musculoskeletal-related injuries and disabling conditions represent the fastest-growing subset of military disability claims over the last 30 years. From 1981 to 2005, the number of disabling conditions related to the musculoskeletal system increased from 70/100,000 persons to 950/100,000 persons for those exiting the military (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). While there are many factors, such as an increase in combat missions or an increasing recognition of disabling conditions, that may account for this increase, recent analysis has shown that the almost 12-fold increase in musculoskeletal disability claims is coming largely from young, enlisted servicemen and servicewomen with lower levels of education (The changing profile of disability in the U.S. Army: 1981–2005. Disabil Health J 1(1):14–24, 2008). These disabling conditions require a disproportionately large amount of resources to care for (Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis. Arthritis Rheum 41(7):1233–40, 1998; Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 23(4):261–6, 2009; Evaluating the predictive value of osteoarthritis diagnoses in an administrative database. Arthritis Rheum 43(8):1881–5, 2000), and it is imperative to have a basic understanding of these ailments to develop and implement effective injury prevention strategies and to optimize the care provided to these patients (An update on the relationship between occupational factors and osteoarthritis of the hip and knee. Curr Opin Rheumatol 14(2):89–92, 2002). This chapter discusses the burden of disability associated with some of the more common musculoskeletal injuries and conditions seen within the military.

Falls in a Young Active Amputee Population: A Frequent Cause of Rehospitalization?

Falls occur in up to 50% of amputees within a single year of their operation and up to 40% of these falls result in injury. However, there is a lack of data evaluating falls in a young, active amputee population despite an estimated 58% of persons living with an amputation being under the age of 65. The authors evaluated an amputee population (n = 393) with a mean age of 25.53 years. Overall incidence, prevalence, fall characteristics, and risk factors were calculated for falls resulting in rehospitalization. An incidence of 1.92 per 1,000 person years with a prevalence of 2.04% was found with 87.5% occurring within the first 6 months following definitive amputation. Of the patients rehospitalized, 75% required at least 1 surgical procedure. Infectious complications had the most significant morbidity requiring a mean of 5 operative procedures. Those that delayed evaluation (mean = 13 days) vs. those that presented 0 to 1 day from a fall were significantly more at risk of an infectious complication (p = 0.03). This study is the first to report such a relationship, and emphasizes the need for at-risk patients to seek early medical attention as this may minimize the risk of infection and obviate the need for surgical intervention.

Trends in firearm safety—do they correlate with fewer injuries

Firearm-related violence within the USA occurs at a much higher rate than other developed countries. While this rate is likely multifactorial in nature, a common debate within households and governments alike involves increased regulation of firearms in hopes of curtailing this violence. This article provides context in which to consider both the pros and cons of increased firearm regulation and a review of the effects certain regulations have had on firearm-related violence thus far.