Edward D. Arrington

Forward surgical team (FST) workload in a special operations environment: the 250th FST in operation ENDURING FREEDOM

PURPOSE Forward Surgical Teams (FST) deploy to support conventional combat units of at least regimental size. This report examines the injuries and treatments of an FST in an environment of unconventional tactics, limited personal protection, and extended areas of responsibility during Operation ENDURING FREEDOM. METHODS A prospective evaluation of the personal protective measures, mechanisms of injury, types of injuries, and times to treatment in Operation ENDURING FREEDOM. Additionally, per-surgeon caseloads, operative interventions, and outcomes are examined. The first phase of this deployment involved co-locating with an Air Force Expeditionary Medical Squadron at Seeb Air Base, Oman (SABO). The second phase involved stand-alone operations at Kandahar International Airport (KIA). Participants include U.S. Special Forces, conventional U.S forces, coalition country special forces, and anti-Taliban Afghan soldiers. RESULTS During the deployment, the FST performed 68 surgical procedures on 50 patients (19 SAB, 31 KIA). There were 35 orthopedic cases (2 to 28 per surgeon), 30 general surgery cases (2 to 10 per surgeon), and 3 head/neck cases. Mechanism of injury included non-battle injury (13), bomb blast (13), gunshot wounds (8), mine (8), and grenades (5). Primary injuries were to the extremities in 27, torso in 9, and head/neck in 11. Three patients had appendicitis. Five patients were wearing body armor, whereas 4 wore helmets. The mean Relative Trauma Score was 7.4. Thirty-one patients were treated at KIA with a mean time to operative treatment of 2.7 +/- 2.7 hours, whereas 19 were treated in SABO with a mean time to operative treatment of 12.4 +/- 15.1 hours. Nine patients received transfusions. Three nonoperative patients died of wounds. CONCLUSION Despite the lack of personal protective gear, most patients had extremity wounds as their primary injuries. In this special operations environment, time to operative treatment was significantly longer than expected.

Application of the Mangled Extremity Severity Score in a Combat Setting

OBJECTIVE The aim of this study was to examine the Mangled Extremity Severity Score (MESS) in a combat setting. METHODS Data on extremity injuries were collected from a forward surgical team. MESS and Revised Trauma Score values were retrospectively calculated for each patient. Students t test was used to compare amputated and salvaged limbs. RESULTS A total of 60 extremities was identified in 49 patients. There were 10 major vascular repairs (20%). MESS values differed significantly for the eight amputations performed (mean MESS, 7.87 +/- 1.91) and 50 salvaged extremities (mean MESS, 2.44 +/-_ 0.438; p = 0.001). CONCLUSIONS A MESS of >7 correlated with amputation, thus validating the MESS in a combat setting. A young average patient age and high-energy injury mechanism on the battlefield leave ischemic time and shock as the most important factors in dictating whether a MESS is >7 or <7.

Septic arthritis following anterior cruciate ligament reconstruction: a comprehensive review of the literature.

Septic arthritis following anterior cruciate ligament (ACL) reconstruction is an uncommon but potentially serious complication. The incidence of infection is approximately 0.44%. Staphylococcus and streptococcus strains are the most common infectious pathogens. Infection is typically via direct inoculation. Articular cartilage damage is primarily the result of the unregulated host inflammatory response. The timing of presentation is typically <2 months following surgery. Presenting symptoms commonly mirror normal postoperative findings, making diagnosis difficult. Although laboratory inflammatory markers are often elevated, knee arthrocentesis is the gold standard for diagnosis. Treatment involves serial arthroscopic or open irrigation and debridement procedures and antibiotic management. Graft retention is often possible, although fixation implants may require removal or exchange. Successful results have been reported following infection eradication in both graft retention and early revision ACL reconstruction scenarios.

Scapular Osteochondromas Treated With Surgical Excision

A retrospective review was performed of all osteochondroma excisions at our institution from 1994 to 2007. Postoperative functional assessment was completed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) survey and a self-report questionnaire. Eight osteochondromas were excised at a mean patient age of 21.63 years. Presenting reports included pain, mass, pseudowinging, and snapping of the scapula. Physical examination identified pseudowinging, palpable mass, and pain with shoulder motion. The lesions arose from the ventral surface of the scapula in 5 patients, the dorsal surface in 2, and the inferior acromion in 1. The resected specimen averaged 10.8cm(3). A reactive bursa was found and resected in 4 patients. At mean of 4.17 years postresection, no signs of recurrence were found in 7 patients (88%). The single patient with a recurrence had undergone 2 additional surgical procedures. Six patients (75%) reported no/mild pain with routine and strenuous activities. One patient reported moderate and 1 patient reported moderate/severe pain with routine and strenuous activities. Four patients reported post-resection function as excellent, 2 as good, 1 as average/good, and 1 as average/poor. Six patients (75%) reported feeling very satisfied with the results, 1 reported feeling satisfied, and 1 reported feeling unsatisfied. The average DASH score was 11.7 (range, 0.00-46.67). No winging or pseudowinging was identified in those available for examination, and no difference was identified in range of motion comparing the operative to the nonoperative upper extremity. Near normal functional outcomes can be expected following excision of scapular osteochondromas.

Comparison of complication rates of intramedullary pin fixation versus plating of midshaft clavicle fractures in an active duty military population.

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 = .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group.

Allograft osteochondral transplantation in the knee in the active duty population.

The purpose of this study is to analyze the role of allograft osteochondral transplantation in the knee in the active duty population, focusing on the patients ability to remain on active duty following the procedure. A retrospective review was performed on all active duty patients undergoing allograft osteochondral transplantation surgery of the knee at our institution from 2003 to 2011. Medical records were reviewed for patient characteristics and treatment details. Eighteen patients underwent osteochondral transplantation surgery from 2003 to 2011. One of the patients is still in the acute recovery phase of their procedure (<1 year since surgery), and one patient was already in the medical evaluation board (MEB) process at the time of surgery. Of the remaining sixteen patients, nine have either entered or completed the MEB since surgery. Six of the seven patients who have stayed on active duty remain on activity-restricting profiles. The average time from surgery to MEB for these patients was 23.2 months. In the setting of the unique demands of active duty soldiers, osteochondral allograft transplantation does not appear to be conducive to retention on active duty.

Instrumentation-Specific Infection After Anterior Cruciate Ligament Reconstruction

Background: Anterior cruciate ligament (ACL) reconstruction is uncommonly complicated by postoperative infections, the causes of which are rarely identified. Hypothesis/Purpose: The goal of this study was to characterize the relationship between methodological sterilization failure and ACL reconstruction infection at an army medical center. Study Design: Case series. Methods: Demographic, clinical, and laboratory data were collected on 5 postoperative infections during a 14-week period in 2003. All ACL reconstructions completed within the past 6 years at the institution were reviewed to establish a baseline infection rate. Results: There was a 14-week period in which 5 cases of infection occurred postoperatively, an infection rate of 12.2%. Previous and subsequent to the identified period, the established rate of infection after ACL reconstruction was 0.3%. There were no violations of sterile technique noted in any of the identified cases. All cases utilized hamstring autograft. All cases also used the DePuy Mitek Intrafix system for tibial fixation of the graft. Two of these cases had positive cultures. Conclusions: An isolated series of increased infection rate led to an investigation into the sterile technique. This revealed gross biomaterial remaining inside instrumentation common to all the cases, the DePuy Mitek Intrafix system. The modular cannulated hex driver, made to fit over a small caliber wire, had no wire brushes of a small-enough diameter for the cleaning and sterilization procedure. After recognition of infection, all patients were treated with surgical irrigation and debridement of the affected knee, as well as individualized antibiotic therapy. Patients were followed postoperatively and no patients required revision ACL reconstruction or radical debridement of the graft.

Iatrogenic Nerve Injuries in Shoulder Surgery

Abstract The range of open and arthroscopic shoulder procedures continues to evolve and expand. Despite advances in instrumentation and technology, complications still exist and neurologic injury remains an inherent part of these procedures. Iatrogenic nerve injuries are among the more commonly cited complications associated with shoulder surgery. Various surgical procedures about the shoulder are known to place the brachial plexus and peripheral motor nerves at risk. Peripheral nerve monitoring has been helpful in identifying specific surgical steps and key anatomic regions that are susceptible to iatrogenic nerve injury.

Monitoring of somatosensory and motor evoked potentials during open reduction and internal fixation of pelvis and acetabular fractures

Monitoring of motor and somatosensory evoked potentials provides instantaneous intraoperative assessment of a patients neurologic status. Monitoring of the sciatic nerve through motor and somatosensory evoked potentials can be used during open reduction and internal fixation of pelvic and acetabular fractures. A review of 12 pelvic and acetabular fractures treated with open reduction and internal fixation was conducted and assessed with a combination of intraoperative motor and somatosensory evoked potential monitoring. Results revealed intraoperative motor evoked potential monitoring was 100% sensitive and 100% specific in predicting postoperative sciatic nerve deficits, whereas somatosensory evoked potentials were not accurate in predicting postoperative sciatic nerve deficits. Combined monitoring of the sciatic nerve with motor and somatosensory evoked potentials is beneficial at predicting postoperative sciatic nerve deficits during open reduction and internal fixation of pelvic and acetabular fractures.

Early Postoperative Failure of a New Intramedullary Fixation Device for Midshaft Clavicle Fractures

The Sonoma CRx device (Sonoma Orthopedic Products, Santa Rosa, California) is a recently introduced intramedullary device with a flexible shaft that becomes rigid once actuated to allow deployment within the sigmoidal contour of the clavicular shaft. Medial intramedullary cortical purchase is obtained by grippers and lateral purchase through a locking bicortical buttressing screw. This article describes 2 cases of early hardware failure using this device. In both cases, early postoperative radiographs demonstrate adequate initial fracture reduction and implant position. Both patients sustained repeat injuries, one under low physiologic load and the other after returning to mixed martial arts 4 months postoperatively. Implant failure was noted after reinjury in both cases. Complete healing and full return to function was documented for both patients at 2 years. Proper patient selection and counseling regarding the limitations of this intramedullary fixation device are important. Biomechanical comparison of this implant to plate fixation under physiologic loads of combined axial compression and torsion may shed light on differences in fixation stability.